Clinical Impact of Pretransplantation Physical Function on Transplantation after Allogeneic Hematopoietic Cell Transplantation in Older Adults

Clinical research regarding the impact of pretransplantation physical function on transplantation outcomes in older adults remains limited. We retrospectively reviewed the charts of 150 consecutive patients age >55 years who underwent their first allogeneic hematopoietic cell transplantation (HCT) at our center between 2010 and 2021. We evaluated the clinical impact of pretransplantation physical function, including hand grip strength (HGS), knee extension strength (KES), and distance covered in a 6-minute walk test (6MWT), along with other clinical factors, on transplantation outcomes such as overall survival (OS), nonrelapse mortality (NRM), and cumulative incidence of disease relapse (CIR). There was no difference in OS, NRM, or CIR among the 3 age groups studied (56 to 60 years, 61 to 65 years, and 66 to 70 years). With regard to physical function tests, we divided the study patients into 2 groups based on the median HGS, KES, and 6MWT values: higher physical function and lower physical function groups. Because there were significant differences in HGS and KES between male and female patients, sex-specific threshold values were used. In a univariate analysis, OS tended to be better in the higher physical function group compared with the lower physical function group (4-year OS, 42.0% versus 32.0% in HGS, P = .14; 44.8% versus 37.8% in KES, P = .17; 46.7% versus 30.5% in 6MWT, P = .099). NRM was significantly lower in the higher physical function group (4-year NRM, 25.5% versus 39.9% in HGS, P = .045; 17.7% versus 38.0% in KES, P = .005; 22.5% versus 43.4% in 6MWT, P = .033). There was no significant difference in CIR between the higher and lower physical function groups (4-year CIR, 34.6% versus 28.7% in HGS, P = .38; 38.5% versus 25.8% in KES, P = .20; 33.0% versus 27.0% in 6MWT, P = .42). In multivariate analysis, the higher KES group (hazard ratio [HR], .54; 95% confidence interval [CI], .32 to .90) was significantly associated with better OS, as were female sex (HR, .48; 95% CI, .26 to .89) and low/intermediate Disease Risk Index (HR, 3.59; 95% CI, 2.04 to 6.31). Higher KES (HR, .37; 95% CI, .17 to .83) and female sex (HR .36; 95% CI, .13 to .998) were significantly associated with a reduced risk of NRM. Higher HGS and higher 6MWT tended to be associated with a reduced risk of NRM, but this trend was not statistically significant. Pretransplantation physical function, particularly the strength of the lower extremities, but not chronological age, is associated with NRM and OS after allogeneic HCT in adults age >55 years.

Substitution of calcineurin inhibitors with corticosteroids after allogeneic hematopoietic cell transplantation

Combination of calcineurin inhibitors (CIs) with short-term methotrexate is a standard prophylactic regimen for graft-versus-host disease (GVHD). However, it is sometimes difficult to continue CIs due to adverse effects, such as renal impairment and fluid overload. In such cases, we replace CIs with corticosteroids, considering that full dose of CIs is equivalent to prednisolone (PSL) at 1 mg/kg. We retrospectively evaluated the clinical significance of replacement of CIs with corticosteroids after allogeneic hematopoietic cell transplantation (HCT). We evaluated 42 patients switched from CIs to corticosteroids within 90 days among the 479 patients who underwent allogeneic HCT at our center between 2007 and 2019. Renal impairment (n = 33), fluid overload (n = 13), and thrombotic microangiopathy (n = 3) were the main reasons for switching. Although creatinine and body weight returned to baseline at 4 weeks after switching, 100-day non-relapse mortality was high (57.1%). Grade II-IV acute GVHD was seen in 10 (24.4%) patients who did not have it before switching treatment (n = 41). In conclusion, CIs were switched to corticosteroids in patients with severe clinical conditions. The incidence of acute GVHD was acceptable. Although the short-term mortality rate was high, improvement of renal function or fluid overload was observed in a certain proportion of the patients.

Plasma ubiquitin C-terminal hydrolase-L1 (UCH-L1) level as a blood biomarker of neurological damage after allogeneic hematopoietic cell transplantation

Several biofluid-based biomarkers for traumatic brain injury show promise for use in diagnosis and outcome prediction. In contrast, few studies have investigated biomarkers for non-traumatic brain injury. We focused on ubiquitin C-terminal hydrolase-L1 (UCH-L1), which has been proposed as a screening tool for traumatic brain injury, and investigated whether the plasma UCH-L1 level could also be a useful biomarker in patients with non-traumatic brain injury. We measured UCH-L1 in 25 patients who had experienced neurological complications after allogeneic hematopoietic cell transplantation (HCT) and 22 control patients without any complications or graft-versus-host disease. Although UCH-L1 levels before HCT did not differ significantly (P = 0.053), levels after HCT were higher in patients with neurological complications compared with the control group (P < 0.001). At a UCH-L1 cutoff value of 0.072 ng/ml, sensitivity was 68.0% and specificity was 100%. The statistical power of UCH-L1 for neurological complications seemed to be higher than that of CT and comparable to that of MRI. Thus, increased levels of UCH-L1 might reflect the presence of neurological damage even in patients with non-traumatic brain injury. Further large cohort investigations are warranted.

Gene expression and TCR amino acid sequences selected by HLA-A02:01-restricted CTLs specific to HTLV-1 in ATL patients

Adult T-cell leukaemia/lymphoma (ATL) is an aggressive malignancy of peripheral T cells caused by human T-cell lymphotropic virus type-1 (HTLV-1). Tax is the most important regulatory protein for HTLV-1. We aimed to reveal a unique amino acid sequence (AA) of complementarity-determining region 3 (CDR3) of the T-cell receptor (TCR)β and TCRα chains of HLA-A*02:01-restricted Tax11-19 -specific cytotoxic T cells (Tax-CTLs). The gene expression profiles (GEP) of Tax-CTLs were assessed by the next-generation sequence (NGS) method with SMARTer technology. Tax-CTLs seemed to be oligoclonal, and their gene compositions were skewed. The unique motifs of 'DSWGK' in TCRα and 'LAG' in TCRβ at CDR3 were observed in almost all patients. Tax-CTL clones harbouring the 'LAG' motif with BV28 had a higher binding score than those without either of them, besides a higher binding score associated with longer survival. Tax-CTLs established from a single cell showed killing activities against Tax-peptide-pulsed HLA-A2+ T2 cell lines. GEP of Tax-CTLs revealed that genes associated with immune response activity were well preserved in long-term survivors with stable status. These methods and results can help us better understand immunity against ATL, and should contribute to future studies on the clinical application of adoptive T-cell therapies.

Clinical features of febrile neutropenia and bloodstream infection in autologous hematopoietic cell transplantation: Comparison to those in intensive chemotherapy for acute myeloid leukemia

BACKGROUND

In autologous hematopoietic cell transplantation (HCT), myelosuppression and mucosal damage are more severe than those in conventional chemotherapy because of high-dose chemotherapy, but the duration of neutropenia is shorter due to stem cell rescue.

METHODS

We retrospectively evaluated febrile neutropenia (FN) and bloodstream infection (BSI) in 208 patients who underwent their first autologous HCT at our institution between 2007 and 2019. They were compared to those in patients who underwent intensive chemotherapy for acute myeloid leukemia (AML) (130 induction/salvage and 191 consolidation).

RESULTS

The median neutropenic period in autologous HCT, AML induction/salvage and consolidation was 9, 26.5, and 19 days, respectively. The incidence of FN was 93.8%, 92.3%, and 81.7%, and that of BSI in initial FN was 7.2%, 7.5% and 26.3%, respectively. The incidence of oral mucositis (≥ grade 2) was 63.1%, 9.2% and 12.2%, and that of diarrhea (≥ grade 2) was 53.3%, 9.2% and 6.4%, respectively. Although there were significant differences in the incidence of shaking chills, the degree of fever and the value of CRP between patients with and without BSI in initial FN of AML chemotherapy, no significant risk factors or predictive factors for BSI were identified in autologous HCT.

CONCLUSIONS

The profile of infectious complications in autologous HCT was characterized by a high incidence of FN maybe due to mucosal damage. On the other hand, the incidence of BSI was lower compared to that in AML consolidation chemotherapy.

Very early death within 30 days after diagnosis in patients with acute myeloid leukemia

Acute myeloid leukemia (AML) is a malignancy that requires immediate treatment. However, the factors that predict very early mortality are not well known. We retrospectively analyzed 70 patients who were newly diagnosed with AML at our institution between 2014 and 2020. Very early death within 30 days after the initial consultation with a hematologist occurred in eight patients, including seven men. They were older than 30-day survivors (70.5 vs. 47 years, P < 0.01). In addition, four patients with a low score on the Glasgow Coma Scale (GCS) at diagnosis died within 30 days, and half of the early death group died due to cerebral hemorrhage. We next tried to predict early death using a ROC curve. Age, hemoglobin (Hb), estimated glomerular filtration rate (eGFR) and the international normalized ratio of prothrombin time (PT-INR) all had an area under the curve of greater than 0.8 for predicting very early death. A multivariate analysis revealed that older age (OR = 1.14, P = 0.033), Hb (OR = 0.48, P = 0.05), and low GCS (OR = 140.0, P = 0.0073) were significantly associated with very early death. Further studies will be needed to confirm which patients are at high risk for early death and to improve the treatment strategy for such patients.

Chronic active Epstein-Bar virus infection complicated by pulmonary artery hypertension

Chronic active Epstein-Bar virus infection (CAEBV) is known to cause various symptoms. Although pulmonary artery hypertension (PAH) has been reported as a cardiovascular complication of CAEBV, the mechanisms of PAH and the effects of treatment have not been fully elucidated. We experienced 4 adult patients with CAEBV complicated by PAH. All of them received treatment for PAH with a vasodilator followed by chemotherapy with or without allogeneic hematopoietic cell transplantation for CAEBV. In all of these patients, the transtricuspid pressure gradient improved under treatment with vasodilator, and further improvement was observed under treatment for CAEBV in 3 patients. Autopsy was performed in 2 patients, which revealed EBER-positive cells and a change in the pulmonary artery at each stage in the pathology. In conclusion, EBV-infected cells can cause vasculitis and finally PAH. However, PAH complicated with CAEBV can be improved by PAH medication and treatment of CAEBV.

[Anti-MDA5 antibody-positive rapidly progressive interstitial lung disease after allogeneic hematopoietic cell transplantation successfully treated with triple immunosuppressive therapy]

A 34-year-old man with KMT2A-MLLT1 acute myeloid leukemia in first complete remission underwent allogeneic peripheral blood stem cell transplantation from his HLA-matched sister after conditioning with busulfan/cyclophosphamide. He did not have severe graft-versus-host disease, but he developed interstitial pneumonia six months after transplantation when his oral cyclosporine A (CsA) dose was reduced to 10 mg/day. He was given prednisolone (PSL), which temporarily improved his respiratory condition, but he quickly deteriorated when PSL was reduced. Anti-MDA5 antibody was found to be positive after additional testing, and a three-drug combination of intravenous cyclophosphamide+PSL+CsA was initiated for anti-MDA5 antibody positive rapidly progressive interstitial lung disease, which was effective for interstitial pneumonia. He received a successful living-donor lung transplant from his younger brother and sister. We present a case of rapidly progressive anti-MDA5 antibody positive interstitial lung disease in which the patient's respiratory condition improved after triple therapy and subsequent living-donor lung transplantation.

Pancreatic atrophy and recovery after allogeneic hematopoietic cell transplantation

BACKGROUND

Pancreatic atrophy after allogeneic hematopoietic cell transplantation (HCT) is one of the symptoms associated with chronic graft-versus-host disease (GVHD). Although pancreatic atrophy has been considered to cause exocrine insufficiency and weight loss, it is not yet clear what kinds of recipients can be expected to recover their body weight (BW) or pancreatic thickness. In addition, the effect of pancreatic atrophy on the prognosis has not been clarified.

METHODS

We retrospectively analyzed 170 recipients who received allogeneic bone marrow transplantation or peripheral blood stem cell transplantation, and evaluated them using the CT scan images obtained closest to 1, 2, 3, and 4 years after HCT.

RESULTS

Fifty-five recipients (32.4%) demonstrated pancreatic atrophy, and 11 (20%) of them recovered their pancreatic thickness. While recipients without pancreatic atrophy gradually recovered their BW (P < 0.001), those with atrophy did not (P = 0.12). Moderate and severe chronic GVHD tended to be slightly more common in the atrophy group (47.3% vs 38.3%), whereas the pancreatic thickness tended to recover in these recipients (30.8% vs 10.3%). HCT from a female donor to a male recipient showed superior pancreatic recovery compared to other donor and recipient sex combinations. Pancreatic atrophy treated as a significantly associated with inferior survival (HR 4.91, P < 0.001) and an increased risk of non-relapse mortality (HR 8.75, P < 0.001).

CONCLUSIONS

These results suggest that it is important to monitor pancreatic thickness after HCT. Further prospective investigations are warranted to clarify the significance of pancreatic atrophy on clinical outcomes.

Persistent Expression of Recipient-type ABH Antigen after ABO-incompatible Allogeneic Hematopoietic Stem Cell Transplantation

In general, the recipient's ABO blood type changes to the donor's ABO blood type after ABO-incompatible allogeneic hematopoietic stem cell transplantation (HSCT). However, we experienced a 26-year-old male with acute myelogenous leukemia (AML) who underwent ABO-incompatible HSCT twice and persistently showed his original blood type even after demonstrating complete donor-type chimerism. Based on the results of various examinations, we considered that the antigen of the recipient's original blood type persistently synthesized in the recipient's non-hematopoietic organs was secreted and adsorbed on the surface of donor-derived RBCs. We should therefore perform detailed examinations to determine the precise blood type after ABO-incompatible HSCT.

Successful treatment of the TEMPI syndrome with pomalidomide plus dexamethasone followed by autologous stem cell transplantation

TEMPI syndrome is a rare disease associated with plasma cell neoplasms. Although previous studies have reported that bortezomib is effective as a 1st-line treatment for TEMPI syndrome, some cases are refractory to this treatment. Pomalidomide, a kind of immunomodulatory drugs, is widely used for the treatment of relapsed or refractory multiple myeloma and could be administered without dose modification in patients with renal dysfunction. We present a case of bortezomib-refractory TEMPI syndrome with renal insufficiency that was successfully treated with a combination of pomalidomide and low-dose dexamethasone with minimal adverse effects, followed by autologous hematopoietic stem cell transplantation. To the best of our knowledge, this is the first case of TEMPI syndrome that was successfully treated with pomalidomide. Pomalidomide may be suitable for patients who do not respond to a proteasome inhibitor-based treatment. In addition, a subsequent ASCT could also be effective for achieving a further treatment response.

Prognostic impact of chromosomal changes at relapse after allogeneic hematopoietic cell transplantation for acute myeloid leukemia or myelodysplastic syndrome

Chromosome analysis is a powerful prognostic tool in myeloid malignancies. Recipients who experience relapse after allogeneic hematopoietic cell transplantation (allo-HCT) often show chromosomal changes between diagnosis and relapse. However, the clinical impact of chromosomal changes and the efficacy of post-relapse treatment according to chromosomal changes have not been fully investigated. We retrospectively analyzed 72 recipients who had experienced relapse after allo-HCT for acute myeloid leukemia or myelodysplastic syndrome. We categorized them into two groups: with or without clonal chromosomal changes at relapse after allo-HCT. Post-relapse survival was shorter in the clonal chromosomal change group (median 117 days vs 275 days, P = 0.019). Moreover, acquisition of chromosome 7 abnormality or complex changes tended to be associated with inferior survival in a univariate analysis (median 92 days vs median 173 days, P = 0.043), and this adverse impact was confirmed in a multivariate analysis (hazard ratio 2.07, P = 0.024). The patterns of chromosomal changes from diagnosis to relapse after allo-HCT were heterogenous, and further investigations are required to clarify the effect of individual chromosomal changes.

Neutropenia in the First Cycle of Consolidation Chemotherapy with High-Dose Cytarabine Is Not Associated with the Incidence of Relapse in Adult Acute Myeloid Leukemia Patients in First Complete Remission

BACKGROUND

It has been reported that prolonged neutropenia during post-remission chemotherapy is associated with a reduced risk of disease relapse in pediatric acute myeloid leukemia (AML) patients.

METHODS

We retrospectively reviewed the charts of adult AML patients in first complete remission (CR1) who underwent consolidation chemotherapy with high-dose cytarabine. Those receiving allogeneic hematopoietic cell transplantation in CR1 were excluded. We calculated the D-index, which is an area-based neutropenia index. The patients were divided into 2 groups using the median value of the D-index during the first cycle of consolidation chemotherapy (C#1).

RESULTS

Fifty-six patients were included. The 2-year cumulative incidence of relapse was 54.8% (95% confidence interval (CI): 37.5-73.8) in patients with a D-index < 5,118 and 62.0% (95%CI: 42.7-81.4) in those with a D-index ≥ 5,118 (P = 0.56). In a multivariate analysis, intermediate / adverse cytogenetic risk (HR 2.76), performance status ≥ 2 (HR 5.55) and 2 cycles of induction chemotherapy required to achieve CR1 (HR 4.29) were identified as significant factors associated with relapse. The D-index at C#1 did not have a significant impact.

CONCLUSIONS

In contrast to pediatric patients, the severity of neutropenia is not associated with a risk of disease relapse in adult AML patients.

Association between the kinetics of cytomegalovirus reactivation in terms of the area under the curve of cytomegalovirus antigenemia and non-relapse mortality after allogeneic hematopoietic stem cell transplantation

BACKGROUND

We assessed the kinetics of cytomegalovirus (CMV) reactivation using the area under the curve (AUC), which simultaneously reflects both the viral load at each time point and the duration of CMV antigenemia (CMV-AG).

METHODS

We performed a single-institute retrospective analysis in patients who received allogeneic hematopoietic stem cell transplantation (HSCT) between 2007 and 2017 and survived more than 100 days after HSCT. The AUC of CMV-AG (CMV-AUC) was calculated by a trapezoidal method using the number of CMV-AG tested by the C10/C11 method after logarithmic transformation, and plotted weekly up to day 100.

RESULTS

CMV reactivation was observed in 195 cases and the median CMV-AUC for CMV-reactivated patients was 8.7 (range 0.5-30.7). Older age, corticosteroid administration, CMV-seropositive transplant recipients, HSCT from an unrelated donor, and underlying diseases were independent predictive factors for higher CMV-AUC. Higher CMV-AUC was associated with poor overall survival (OS) with borderline significance in a univariate analysis (p = .07), but was not significant in a multivariate analysis. Older age, high-risk disease status, and female gender were identified as significant factors associated with poor OS in this study. On the other hand, CMV-AUC (hazard ratio: no reactivation reference, low 0.98, high 2.49, p < .01), older age, HCT-CI ≥3, and corticosteroid administration were identified as significant factors associated with increased incidence of non-relapse mortality (NRM).

CONCLUSIONS

The kinetics of CMV reactivation in terms of CMV-AUC reflect both the severity and duration of CMV reactivation. High CMV-AUC was associated with an increased incidence of NRM in survivors over 100 days.

Prediction of Cytomegalovirus Reactivation by Recipient Cytomegalovirus-IgG Titer before Allogeneic Hematopoietic Stem Cell Transplantation

Recipient cytomegalovirus (CMV) seropositivity is known to be a risk factor for CMV reactivation after allogeneic hematopoietic stem cell transplantation (allo-HCT). We explored the association of CMV-IgG titer of recipients with CMV reactivation after allo-HCT and developed a model for predicting CMV reactivation for the purpose of identifying a high-risk group. In addition, we evaluated the impact of CMV-IgG titer on survival outcomes and acute graft-versus-host disease (GVHD). We retrospectively analyzed 309 patients who achieved neutrophil engraftment after allo-HCT and evaluated whether pretransplantation recipient CMV-IgG titer was associated with transplantation outcomes, including CMV reactivation. Using the best cutoff value determined by a receiver operating characteristic curve analysis, we divided the study cohort into 3 groups: high-titer, low-titer, and negative. CMV reactivation occurred most frequently in the high-titer group, followed by the low-titer and negative groups (81%, 37%, and 16%, respectively, at 180 days after allo-HCT; P < .01). In a multivariate analysis, recipient CMV-IgG titer was significantly associated with subsequent CMV reactivation (hazard ratio [HR], 9.31 in the high-titer group [P < .01] and 2.91 in the low-titer group [P = .023]). CMV diseases were observed exclusively in the high-titer group. Overall survival (OS) was lower in the high-titer group compared with the other 2 groups (2-year OS, 56%, 60%, and 80%, respectively; P = .075), whereas the cumulative incidences of grade II-IV acute GVHD, nonrelapse mortality (NRM), and relapse were not significantly different among the 3 groups. In multivariate analyses, CMV-IgG titer was not associated with increased risks of these outcomes, although CMV reactivation itself was identified as a risk factor for NRM (HR, 3.05; P = .002). Our data demonstrate that a higher titer of recipient CMV-IgG is predictive of CMV reactivation after allo-HCT. Further investigation is needed to determine how to apply these results to prophylactic or preemptive strategies against CMV, considering recipient CMV-IgG titer for effective risk stratification.

Immunity and Vaccination Against Measles, Mumps, and Rubella in Adult Allogeneic Hematopoietic Stem Cell Transplant Recipients

Large outbreaks of measles or rubella occasionally occur around the world, and measles infection can be severe and even fatal in transplant patients. However, limited data are available on immunity to measles, mumps, and rubella (MMR) in adult patients after allogeneic stem cell transplantation (allo-HCT). The aim of this study was to evaluate the immune status against MMR and the effects of vaccination against MMR in adult patients after allo-HCT. A total of 135 adult patients who were alive without relapse and new malignancy at 2 years after allo-HCT were included in this study. We measured IgG antibody to MMR before allo-HCT and annually thereafter. The probabilities of being seropositive to measles, mumps or rubella after allo-HCT were estimated according to the Kaplan-Meier method and compared among groups with the log-rank test. The probability of being seropositive at 2 years after allo-HCT in patients who were seropositive before allo-HCT was 60.6% for measles, 39.7% for mumps, and 52.2% for rubella. History of chronic graft-versus-host disease tended to be a risk factor for the loss of immunity against measles (hazard ratio [HR] 1.69, P = .064) and rubella (HR 1.75, P = .056). To predict the loss of immunity against MMR at 2 years after allo-HCT, we defined the following cutoff values for the IgG index before HCT: 18.2 for measles, 5.3 for mumps, and 21.4 for rubella using a receiver-operating characteristics curve. The lower-IgG groups experienced a significant loss of seropositivity at 2 years (39% versus 82% for measles, P < .001; 13% versus 59% for mumps, P < .001; and 33% versus 90% for rubella, P < .001). After this loss of immunity, 25 patients received a single vaccination against MMR. The seroconversion rates were 64%, 36%, and 72% for measles, mumps, and rubella, respectively. Loss of immunity to MMR commonly occurs in the first several years after transplantation. In the patients who lose the immunity, the seroconversion rate after 1 dose of MMR vaccine given at ≥2 years after transplantation is suboptimal.

Body Weight Loss Before Allogeneic Hematopoietic Stem Cell Transplantation Predicts Survival Outcomes in Acute Leukemia Patients

Most acute leukemia patients receive consecutive intensive chemotherapy, which usually takes several months before allogeneic hematopoietic stem cell transplantation (allo-HCT). Intensive chemotherapy often induces gastrointestinal adverse events. These adverse events leave patients in a state of malnutrition, leading to a reduction in body weight. In this study, we analyzed the impact of body weight loss before allo-HCT on survival outcomes of acute leukemia patients (acute myeloid leukemia, acute lymphoid leukemia and mixed phenotype acute leukemia). A loss of body weight (LBW), which was a reduction of body weight from diagnosis or relapse to transplantation, was calculated in 182 acute leukemia patients who received first allo-HCT at our center between June 2006 and September 2019. A receiver operating characteristics curve for nonrelapse mortality (NRM) was plotted for defining the cut-off value of LBW. The cutoff value of LBW was defined as 13.2%. A higher LBW was significantly associated with inferior NRM and overall survival (OS) (2-year [2y] NRM 36.1% versus 11.5%, P = .0025; 2y-OS 39.9% versus 65.8%, P = .020). The adverse impact of LBW was also confirmed in multivariate analyses for NRM and OS (HR of NRM 2.74 [1.25-6.03], P = .0012; HR of OS 2.06 [1.00-3.07], P = .0049). The main cause of death included disease progression (n = 34) and infection (n = 35). Death cause by infection was more frequently observed in the high-LBW group (15 cases [35.7%] versus 20 cases [14.3%]; P = .0035). In addition, subgroup analyses based on a combination of the body mass index at diagnosis and LBW were performed. When the non-overweight-low LBW group (body mass index [BMI] ≤25 and LBW ≤13.2%) was used as a reference in multivariate analysis, the overweight-high LBW group (BMI >25 and LBW >13.2%) showed an increased risk of poor survival outcomes (HR of NRM 4.27 [95% confidence interval {CI}, 1.82-10.0], P < .001; HR of OS 1.93 [95%, CI 1.00-3.71], P = .050). High LBW was significantly associated with inferior survival outcomes, and the adverse effect of malnutrition might be greater than the favorable effect of the reduction in overweight.

Autologous Hematopoietic Recovery after Unrelated Umbilical Cord Blood Transplantation with Myeloablative Conditioning for Acute Myelogenous Leukemia

Autologous hematopoietic recovery after allogeneic hematopoietic cell transplantation (allo-HCT) is rare in patients who receive myeloablative conditioning (MAC). Autologous hematopoietic recovery suggests graft rejection, leading to concerns about subsequent disease relapse. We herein report a rare case of a patient with acute leukemia who experienced autologous hematopoietic recovery after cord blood transplantation (CBT) with total body irradiation-based MAC. Chromosomal abnormalities were repeatedly detected without any disease relapse for eight months. The accumulation of similar cases is required to accurately assess the incidence and clinical outcomes of autologous hematopoietic recovery after CBT with MAC.

Association of the areas over and under the lymphocyte curve with cytomegalovirus reactivation after allogeneic hematopoietic stem cell transplantation

BACKGROUND

We retrospectively compared the impact of the areas over and under the lymphocyte curve (L_AOC vs L_AUC) on cytomegalovirus (CMV) reactivation after allogeneic hematopoietic stem cell transplantation (HSCT).

METHODS

Among 394 consecutive patients who underwent their first allogeneic HSCT at our center between 2007 and 2018, 301 patients met the inclusion criteria. L_AOC was calculated as the area over the lymphocyte curve during lymphopenia (absolute lymphocyte count [ALC] <700/μL). We calculated L_AOC and L_AUC from day 0 to day 15 (L_AOC15, L_AUC15) and from day 0 to day 30 (L_AOC30, L_AUC30).

RESULTS

CMV antigenemia was defined as more than 3 cells/2 slides by the C10/11 method and detected in 204 cases (CMV reactivation) at a median of 39 days after HSCT. Although there were significant differences in L_AOC15, L_AOC30, L_AUC15, and L_AUC30 between patients with and without CMV reactivation, there was no difference in accuracy for predicting CMV reactivation between L_AOC and L_AUC. In a multivariate analysis, L_AOC15 and L_AUC15 were each identified as independent predictive factors for CMV reactivation, along with advanced age and CMV serostatus. However, ALC at day 14 or day 21 was as accurate as area-based indexes such as L_AOC15 and L_AUC15. L_AOC15 and L_AUC15 were significantly associated with longer duration of anti-CMV antiviral therapy while ALC was not.

CONCLUSIONS

L_AOC15 and L_AUC15 had similar impacts on CMV reactivation. Although these area-based indexes were not superior to ALC for predicting CMV reactivation, they might predict patients who need longer duration of antiviral therapy more accurately.

Pre-Hematopoietic Stem Cell Transplantation Lung Computed Tomography as an Alternative to the Pulmonary Function Test during the COVID-19 Pandemic

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The pulmonary function test (PFT) is an important test for risk stratification before allogeneic hematopoietic stem cell transplantation (allo-HCT), although it might be preferable to avoid unnecessary PFT during the COVID-19 pandemic.

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Our computed tomography (CT)-based model for predicting normal PFT showed relatively high specificity (>80%).

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PFT might be omitted in patients with normal CT findings before allo-HCT.

The pulmonary function test (PFT) is an important test for risk stratification before allogeneic transplantation (allo-HCT). However, it might be preferable to avoid PFT as much as possible in the recent era of coronavirus disease 2019 (COVID-19), because PFT requires forced expirations and might produce aerosols, increasing the risk of COVID-19 transmission. Therefore, we tried to predict normal PFT results before allo-HCT based on computed tomography (CT) findings. This study included 390 allo-HCT recipients at our center for whom lung CT images and PFT results before allo-HCT were available. Abnormal CT findings were less likely to be observed in the normal PFT group (47.0% versus 67.4%, P = .015), with a high negative predictive value of 92.9%. In a multivariate analysis, normal CT was significantly associated with normal PFT (odds ratio, 2.47; 95% confidence interval, 1.22 to 4.97; P = .012). A model for predicting normal PFT was constructed based on the results of a multivariate analysis, and the area under the curve of the receiver operating characteristic analysis was 0.656, which gave a sensitivity of 45.5% and a specificity of 86.0%. The relatively high specificity of the model suggested that PFT can be omitted in patients with normal CT findings before allo-HCT.

Impact of neutropenia evaluated in terms of the D-index on invasive fungal disease while on empiric or preemptive antifungal treatment strategy in the early phase after allogeneic hematopoietic stem cell transplantation

BACKGROUND

We retrospectively evaluated the association between the D-index, which reflects both the depth and duration of neutropenia, and proven/probable invasive fungal disease (IFD) early after allogeneic hematopoietic stem cell transplantation (HSCT) at our center (n = 394).

METHODS

The D-index was defined as the area over the neutrophil curve during neutropenia. The cumulative D-index from the start of neutropenia until the development of infection (c-D-index) was also evaluated as a real-time assessment of neutropenia.

RESULTS

There were 19 cases of early proven/probable IFD before and within 1 week after engraftment. Fifteen cases (78.9%) were seen as breakthrough infection while on empiric (n = 7), preemptive (n = 4) or prophylactic (n = 4) antifungal administration with mold-active agents. The c-D-index and lower performance status were identified as independent significant predictive factors for IFD. A receiver operating characteristic (ROC) curve analysis showed that the D-index and c-D-index were more accurate than the simple duration of neutropenia and as accurate as the duration of profound neutropenia for predicting IFD. The sensitivity, specificity, and positive and negative predictive values of the c-D-index using an appropriate cutoff (CO) value (10 644) determined by ROC curve analysis were 73.1%, 63.2%, 9.1%, and 97.9%, respectively. The advantage of the c-D-index to cumulative days of neutropenia in terms of positive and negative predictive values seemed to be small.

CONCLUSIONS

The appropriate CO value for the c-D-index for predicting IFD was as high as 10 644 in allogeneic HSCT with a more frequent use of empiric antifungal therapy. The c-D-index is useful for assessing the risk of breakthrough IFD.

Association between the kinetics of cytomegalovirus reactivation evaluated in terms of the area under the curve of cytomegalovirus antigenemia and invasive mold infection during the post-engraftment phase after allogeneic hematopoietic stem cell transplantation

BACKGROUND

We evaluated the clinical impact of cytomegalovirus (CMV) reactivation calculated in terms of the area under the curve of CMV antigenemia (CMV-AUC) on the development of invasive mold infection (IMI) in the post-engraftment phase after allogeneic hematopoietic stem cell transplantation (HSCT).

METHODS

Among 394 consecutive patients who underwent their first allogeneic HSCT at our center between 2007 and 2018, 335 were included after excluding patients with a past history of invasive fungal disease (IFD), the development of IFD before engraftment, engraftment failure, or early death within 30 days. CMV antigenemia (CMV-AG) was monitored weekly after engraftment and 3 or more cells/2 slides were regarded as positive. CMV-AUC was calculated by the trapezoidal method using the number of CMV-AG after logarithmic transformation and the duration in weeks and was added until negative conversion. Patients with CMV reactivation were divided into low and high CMV-AUC groups using the median value of CMV-AUC as a threshold.

RESULTS

There were 17 proven/probable IMIs including one mucormycosis and 16 probable invasive aspergillosis, and the 2-year cumulative incidence was 1.0% in the negative CMV-AUC group (n = 136), 3.3% in the low CMV-AUC group (n = 98) and 13.8% in the high CMV-AUC group (n = 101) (P = .001). In a multivariate analysis, grade II-IV acute GVHD (HR 3.74) and CMV-AUC (HR low 1.25, high 5.91) were identified as independent significant factors associated with a higher incidence of IMI.

CONCLUSIONS

Cytomegalovirus kinetics evaluated in terms of CMV-AUC were significantly associated with the development of IMI in the post-engraftment phase after allogeneic HSCT.

Impact of the patient's body weight on the efficacy and adverse events of valganciclovir for cytomegalovirus reactivation after hematopoietic stem cell transplantation

While the dose of ganciclovir (GCV) is decided base on patients' body weight (BW), that of valganciclovir (VGCV) is fixed as 900 or 1800 mg/d regardless of the patient's BW in preemptive therapy for cytomegalovirus (CMV) reactivation in hematopoietic stem cell transplantation. We analyzed the impact of the patient's BW on the effectiveness and adverse events (AEs) of VGCV. From March 2004 to February 2017, 27 patients received VGCV as a first-line treatment for CMV reactivation. As a historical control group, we extracted 17 patients who started to receive GCV at a similar timing. We used the following definitions of outcomes: speed of reduction of CMV antigenemia (CMV-AG) as a measure of effectiveness, ratios of baseline and minimum value for white blood cell (WBC) and platelet counts, and ratio of baseline and maximum values for serum creatinine (sCr) as measures of AEs. As a result, there was no significant correlation between average daily dose of VGCV with or without adjusting for the patient's BW and speed of reduction of CMV-AG. On the other hand, the decreases in WBC and platelets and the increase in sCr were significantly correlated with the cumulative dose of VGCV. However, the absolute values of the correlation coefficients did not increase when we analyzed the correlations between the BW-adjusted cumulative dose of VGCV and factors associated with adverse events. There were no significant differences in efficacies or AE parameters between the GCV and VGCV groups. In conclusion, the patient's BW did not significantly affect the effectiveness or adverse events of VGCV.

Increased CD83 expression of CD34-positive monocytes in donors during peripheral blood stem cell mobilization in humans

CD34-positive monocytes (CD34+mono) have recently been identified in grafts mobilized by granulocyte-colony stimulating factor. We analyzed transplant outcomes of 73 patients whose donor's peripheral blood cells were cryopreserved during mobilization. CD34+mono was detected more frequently in male donors (67% vs. 40%, P = 0.03), while the detection of CD34+mono in donors was not associated with the patient background. Although there was no significant difference in overall survival in the whole cohort, the detection of CD34+mono in donors were significantly associated with a decreased risk of non-relapse mortality (HR 0.23, P = 0.035). Fatal infectious events tended to be less frequent in donors with CD34+mono. Gene expression profile analyses of CD34+mono in humans revealed that the expressions of pro-inflammatory cytokines like IL6, CCL3, IL8, VEGFA, and IL1A were elevated in CD34+mono, and those cytokines were enriched in the immune response, especially against infectious pathogens in the gene ontology analyses. In addition, the expression of CD83 was specifically increased in CD34+mono. It might play a role of antigen presentation in the immune network, leading in a clinical benefit against infections. Further investigations will be required to confirm the biological functions and clinical roles of CD34+mono in transplantation.

Updated Clinical Outcomes of Hematopoietic Stem Cell Transplantation Using Myeloablative Total Body Irradiation with Ovarian Shielding to Preserve Fertility

Myeloablative conditioning regimens are associated with severe gonadal toxicity. To preserve ovarian function, we have been investigating ovarian shielding during total body irradiation (TBI) with a myeloablative dose. In this report, we update the clinical outcomes. Female patients with standard-risk hematologic diseases, aged 40 years or younger, who desired to have children, were included (n = 19). The conditioning regimen consisted of TBI at 12 Gy with ovarian shielding and cyclophosphamide (120 mg/kg) or cytarabine (24 g/m²). Ovarian shielding reduced the actual irradiation dose applied to the ovaries from 12 Gy to 2 to 3 Gy. The median age at hematopoietic stem cell transplantation (HSCT) was 24 years (range, 19 to 33 years). With a median follow-up period of 1449 days (range, 64 to 3694) after HSCT, 5-year overall survival and 1- and 5-year relapse rates were 67%, 17%, and 31%, respectively. Only 2 of 14 patients with acute myeloid or lymphoid leukemia in remission have relapsed thus far. The 6-month and 1-year cumulative rates of menstrual recovery were 42% and 78%, respectively. In all patients with menstrual recovery, menstruation recovered within 1 year. The serum anti-Müllerian hormone (AMH) level tended to gradually increase after menstrual recovery. Three patients with extensive chronic graft-versus-host disease experienced delayed recovery of menstruation and serum AMH. Five pregnancies in 3 patients resulted in normal delivery in 1, selective cesarean operation in 1, current pregnancy in 1, and natural abortion in 2. These results suggest that a myeloablative TBI regimen with ovarian shielding could preserve fertility after HSCT without an apparent increase in relapse in standard-risk patients. Because serum AMH recovered gradually over time, the AMH level during the early phase after HSCT may have little value as a marker of ovarian reserve.

Vogt-Koyanagi-Harada Disease Associated with Influenza A Virus Infection

We herein report a case of a 31-year-old Japanese man who simultaneously had a positive influenza A virus antigen test result and Vogt-Koyanagi-Harada disease (VKHD), demonstrated by both diffuse multiple early hyperfluorescent points on fluorescein fundus photography and serous retinal detachments on optical coherence tomography. He had meningitis. It was difficult to determine whether the main cause of meningitis was influenza A or VKHD. After initial treatment with peramivir for influenza A and then methylprednisolone pulse with subsequent corticosteroid therapy for VKHD, his symptoms improved gradually. These findings suggest that influenza A virus infection contributes to the onset or exacerbation of VKHD.

The effect of denture installation at mandibular rest position on unsteady motion of the centre of pressure in postural sway

Wearing dentures has been believed to decrease the instability of the postural sway using the total length of centre of pressure (CoP) trajectory or the magnitude of its variability. However, the physical aspects of the postural sway have not been taken into account while evaluating the CoP in patients who wear dentures. The CoP fluctuations are found to show a random walk process. Therefore, changes in the random movement of CoP caused by wearing dentures should be examined by nonlinear dynamics that enables analysis of the characteristics found in the random movement. We evaluated the effect of complete denture installation on CoP sway for twenty-six edentulous patients by performing the following steps. First, we excluded subjects who did not show crossover in spectral analyses. Then, we evaluated the spectral characteristics and phase shifts of the velocities of CoP sway for the subjects who showed crossover. We found that wearing complete dentures decreased the fluctuations in the high-frequency part of the power spectral density (PSD) and the phase shift in the mediolateral direction. On the other hand, we also found that the use of complete dentures decreased the fluctuations of PSD amplitude in the anteroposterior direction. From the point of view of the kinetic energy of the musculoskeletal system, we suggested that the use of complete dentures could reduce the energy consumption for the standing posture.

Differentiating benign and malignant salivary gland tumours: diagnostic criteria and the accuracy of dynamic contrast-enhanced MRI with high temporal resolution

OBJECTIVE

To determine the optimal diagnostic criterion of dynamic contrast-enhanced MRI (DCE-MRI) for predicting salivary gland malignancy using a dynamic sequence with high temporal resolution, as well as the accuracy of this technique.

METHODS

The DCE-MRI findings of 98 salivary gland tumours (74 benign and 24 malignant) were reviewed. MR images were sequentially obtained at 5-s intervals for 370 s. Two parameters, peak time and washout ratio (WR) were determined from the time-signal intensity curve. The optimal thresholds of these parameters for differentiating benign and malignant tumours were determined, along with the diagnostic accuracy of the criterion using these thresholds.

RESULTS

A peak time of 150 s and a WR of 30% were identified as optimal thresholds. As the criterion for malignancy, the combination of peak time <150 s and WR <30% provided a sensitivity of 79% (19/24), specificity of 95% (70/74) and an overall accuracy of 91% (89/98). Three of the five false-negative cases were malignant lymphomas of the parotid gland.

CONCLUSION

Peak time <150 s with WR <30% comprised the optimal diagnostic criterion in predicting salivary gland malignancy, providing a sensitivity of 79% and specificity of 95%. The use of high temporal resolution might improve the accuracy of DCE-MRI.

ADVANCES IN KNOWLEDGE

Although several studies have reported the usefulness of DCE-MRI in the differential diagnosis of salivary gland tumours, the specific diagnostic criteria employed have differed widely. We determined the optimal criterion and its accuracy using a dynamic sequence with high temporal resolution.

MRI characteristics of rheumatoid arthritis in the temporomandibular joint

OBJECTIVES

The aim of this study was to investigate characteristic MRI findings of rheumatoid arthritis (RA) in the temporomandibular joints (TMJs).

METHODS

61 patients (122 TMJs) with RA in the TMJ and 50 patients (100 TMJs) with temporomandibular disorder (TMD) were included in this study. MR images of these patients were assessed by two oral radiologists for the presence or absence of osseous changes, disc displacement, joint effusion and synovial proliferation. These findings were compared between the two patient groups.

RESULTS

Osseous changes in the condyle and articular eminence/fossa in the RA patient group were significantly more frequent than in the TMD patient group, and were often very severe. Joint effusion was also significantly more frequent in the RA patient group. Synovial proliferation was found in all TMJs in the RA patient group, whereas it was very uncommon in the TMD patient group.

CONCLUSIONS

Severe osseous changes in the condyle and synovial proliferation were considered characteristic MRI findings of RA in the TMJs.

USPIO-enhanced MRI of highly invasive and highly metastasizing transplanted human squamous cell carcinoma: an experimental study

OBJECTIVE

The aim of this study was to investigate the signal intensity characteristics of highly invasive and highly metastasizing transplanted human squamous cell carcinoma using ultra-small super-paramagnetic iron oxide (USPIO)-enhanced MRI and to correlate them with USPIO distribution to tumour components revealed by histological examination.

METHODS

13 nude mice with transplanted human squamous cell carcinoma in the oral cavity were imaged before and 24 hours after intravenous administration of USPIO. The difference in signal intensity between pre-contrast and post-contrast MR images was visually evaluated. For quantitative analysis, signal intensity within a region of interest was measured. Histological findings were correlated with MR findings. The approximate USPIO concentration was evaluated using USPIO phantoms.

RESULTS

Seven tumours had an area showing signal intensity increase on post-contrast T₁ weighted images. Histopathologically, six of those tumours contained a small amount of iron particles in the stroma. The USPIO concentration was presumed low. Two tumours had an area showing signal intensity decrease on post-contrast T₁ and T₂ weighted images. The areas had a large amount of iron particles in the stroma and the USPIO concentration was presumed high. There was a minimal amount of iron particles in tumour parenchymal cells.

CONCLUSIONS

The amount of USPIO accumulation into tumour stroma was considered to affect MR signal intensity. A small amount increases T₁ weighted signal intensity, whereas a large amount decreases T₁ and T₂ weighted intensity. The USPIO accumulation into the tumour parenchyma was not thought to affect MR signal intensity.

Intradermal delivery of recombinant vaccinia virus vector DIs induces gut-mucosal immunity

Antigen-specific mucosal immunity is generally induced by the stimulation of inductive mucosal sites. In this study, we found that the replication-deficient vaccinia virus vector, DIs, generates antigen-specific mucosal immunity and systemic responses. Following intradermal injection of recombinant DIs expressing simian immunodeficiency virus gag (rDIsSIVgag), we observed increased levels of SIV p27-specific IgA and IgG antibodies in faecal extracts and plasma samples, and antibody-forming cells in the intestinal mucosa and spleen of C57BL/6 mice. Antibodies against p27 were not detected in nasal washes, saliva, and vaginal washes. The enhanced mucosal and systemic immunity persisted for 1 year of observation. Induction of Gag-specific IFN-gamma spot-forming CD8(+) T cells in the spleen, small intestinal intraepithelial lymphocytes, and submandibular lymph nodes was observed in the intradermally injected mice. Heat-inactivated rDIsSIVgag rarely induced antigen-specific humoral and T-helper immunity. Moreover, rDIsSIVgag was detected in MHC class II IA antigen-positive (IA(+)) cells at the injection site. Consequently, intradermal delivery of rDIs effectively induces antigen-specific humoral and cellular immunity in gut-mucosal tissues of mice. Our data suggest that intradermal injection of an rDIs vaccine may be useful against mucosally transmitted pathogens.

Differentiation between superficial and deep lobe parotid tumors by magnetic resonance imaging: usefulness of the parotid duct criterion

BACKGROUND

The location of a parotid tumor affects the choice of surgery, and there is a risk of damaging the facial nerve during surgery. Thus, differentiation between superficial and deep lobe parotid tumors is important for appropriate surgical planning.

PURPOSE

To evaluate the usefulness of using the parotid duct, in addition to the retromandibular vein, for differentiating between superficial and deep lobe parotid tumors on MR images.

MATERIAL AND METHODS

Magnetic resonance images of 42 parotid tumors in 40 patients were reviewed to determine whether the tumor was located in the superficial or deep lobe. In each case, the retromandibular vein and the parotid duct were used to locate the tumor. The parotid duct was only used in cases where the tumor and the duct were visualized on the same image.

RESULTS

Using the retromandibular vein criterion, 71% of deep lobe and 86% of superficial lobe tumors were correctly diagnosed, providing an accuracy of 81%. However, the accuracy achieved when using the parotid duct criterion was 100%, although it could be applied to only 28 of the 42 cases. Based on these results, we defined the following diagnostic method: the parotid duct criterion is first applied, and for cases in which it cannot be applied, the retromandibular vein criterion is used. The accuracy of this method was 88%, which was better than that achieved using the retromandibular vein criterion alone.

CONCLUSION

The parotid duct criterion is useful for determining the location of parotid tumors. Combining the parotid duct criterion with the retromandibular vein criterion might improve the diagnostic accuracy of parotid tumor location compared to using the latter criterion alone.

Secretory IgA, salivary peroxidase, and catalase-mediated microbicidal activity during hydrogen peroxide catabolism in viridans streptococci: pathogen coaggregation

Viridans streptococci can kill methicillin-resistant Staphylococcus aureus (MRSA) through the production of hydrogen peroxide (H2O2). However, several hundred viridans streptococci cells are necessary to kill 1 cfu of MRSA. We analyzed the potency of bactericidal and fungicidal effector molecules induced by catabolism of H2O2 in the oral cavity. Secretory IgA (SIgA) and an unidentified salivary component bound Streptococcus sanguinis, a viridans streprococcus, and MRSA into coaggregates. In these coaggregates, salivary peroxidase and the MRSA catalase produced singlet molecular oxygen (1O2) from H2O2 produced by viridans streptococci. SIgA converted 1O2 into ozone, which has potent bactericidal and fungicidal activity. We calculated that <10 cfu of Streptococcus sanguinis were necessary to kill 1 cfu of MRSA in the coaggregate. SIgA, Aspergillus niger catalase, and H2O2 in saliva killed Candida albicans, which is highly resistant to reagent H2O2. Together with indigenous bacteria and innate immunity, SIgA potentially constitutes a novel system that may sustain oral homeostasis.

Transient elevation of intracellular calcium ion levels as an early event in T-2 toxin-induced apoptosis in human promyelotic cell line HL-60

Recently we have reported that T-2 toxin, a trichothecene mycotoxin produced by Fusarium species, is a potent inducer of apoptosis in the human promyelotic cell line HL-60. To clarify the signal transduction pathway of apoptosis primed by T-2 toxin, T-2 toxin-induced apoptosis was investigated in detail using confocal laser microscopy and flow cytometry. Apoptosis in HL-60 cells induced by T-2 toxin was dose dependent when the cells were treated with concentrations of 5-100 ng/ml for more than 2 hr. The apoptosis proceeds through various cell cycle stages of HL-60 cells. Prior to apoptosis, the intracellular calcium ion (Ca+2i) level was markedly elevated within 3-5 min after exposure to T-2 toxin and returned to normal level thereafter. A well-known chelator for Ca+2i, ethylene-N,N,N', N'-tetraacetic acid 4K acetoxymethyl ester (BAPTA-AM), a Ca+2-dependent endonuclease inhibitor ZnCl2, and calpain inhibitor 1 sharply blocked T-2 toxin-induced apoptosis. These results strongly suggest that the Ca+2 signal triggered by T-2 toxin is transduced by the activation of endonuclease and protease, and ultimately evokes apoptosis.

A potential pitfall of MR imaging for assessing mandibular invasion of squamous cell carcinoma in the oral cavity

BACKGROUND AND PURPOSE

Whether MR imaging is superior to CT in evaluating the presence and extent of mandibular invasion by squamous cell carcinoma remains controversial. The purpose of this study was to directly compare the diagnostic accuracy of MR imaging and that of CT.

METHODS

MR and CT images in 51 patients with squamous cell carcinoma of the oral cavity were evaluated for the presence and extent of mandibular invasion. The results were correlated with histopathologic findings.

RESULTS

Twenty-five of 51 patients had histopathologic evidence of mandibular cortical invasion. The tumor involved both the cortex and the bone marrow in all 25 patients and involved the inferior alveolar canal in 5 patients. The sensitivity and specificity for mandibular cortical invasion were 96% and 54% for MR imaging and 100% and 88% for CT, respectively. Those for inferior alveolar canal involvement were 100% and 70% for MR imaging and 100% and 96% for CT, respectively. In both evaluations, the specificity of MR imaging was significantly lower than that of CT (McNemar test, P = .004 in the former and P = .002 in the latter). Chemical shift artifact by bone marrow fat was postulated to be the source of most false-positive cases on MR imaging findings for mandibular cortical invasion. Those for inferior alveolar canal involvement were due to MR imaging visualization of the tumor and surrounding inflammation with similar signal intensity.

CONCLUSION

In assessing the presence and extent of mandibular invasion by squamous cell carcinoma, the specificity of MR imaging was significantly lower than that of CT.

[The evaluation of the complications and its management in 800 patients who underwent the thoracoscopic surgery]

Thoracoscopy has been applied to almost all thoracic surgery as shown (table 1). Besides an opportunity to follow and encounter a trouble during surgery using thoracoscopy, so that it is necessary to become skilled in the prediction and management of complication. Nowadays, there are two options on surgery using thoracoscopy, thoracoscopic surgery (TS) is performed only on in a port and on a mini-thoracotomy with a few ports (video-assisted thoracoscopic surgery: VATS). When changing into emergency or converting into open thoracotomy, a muscle sparing thoracotomy could be available. The symptoms which occurred in the thorax are fundamentally similar during both TS and VATS procedure. However, peculiar dangerous factor existed according to the difference in internal organs, procedures, and diseases. Critical complications during surgery were as follows, i.e., injury of pulmonary vessels and bronchus, tension pneumothorax of the opposite lung and tumor implantation of the chest wall. Basically, standard practice is the most important to avoid an accident and determine whether converting to open thoracotomy should be employed. In the present commentary, we would like to present our experiences and propose regarding management.

Expression of midkine and receptor-like protein tyrosine phosphatase (RPTP)-beta genes in the rat stomach and the influence of rebamipide

BACKGROUND

Midkine has been reported to bind to receptor-like protein tyrosine phosphatase (RPTP)-beta and to play important roles in growth and differentiation of various cells. Midkine is expressed in rat stomach during experimental ulcer healing, suggesting that the midkine-RPTP-beta system has some physiological functions in the stomach. Rebamipide is a mucoprotective drug used for the treatment of gastric ulcers. We have tested the hypothesis that the ulcer healing mechanism stimulated by rebamipide is linked physiologically to the gastric midkine-RPTP-beta system.

MATERIALS AND METHODS

Seven-week-old-male Wistar rats were used. Midkine and RPTP-beta gene expression in rat stomach was investigated by laser capture microdissection coupled with the reverse transcription-polymerase chain reaction (RT-PCR). The effects of rebamipide on midkine and RPTP-beta expression in rat stomach and the gastric epithelial cell line RGM1 were evaluated by RT-PCR and Northern blot analyses.

RESULTS

Midkine and RPTP-beta expression was detected in the gastric mucosal, submucosal and muscle layers. Rebamipide stimulated both midkine and RPTP-beta expression in rat stomach and RGM1 cells.

CONCLUSION

Rebamipide may protect the gastric mucosa by regulating midkine and RPTP-beta expression.

Enhanced hydrolytic stability of dental composites by use of fluoroalkyltrimethoxysilanes

The hydrolytic stability of a group of experimental composite materials was evaluated. Seven distinct composites were formed by the mixing of a resin monomer mixture with silica filler that had been pre-treated with one of 7 different ethanol solutions. In one case, the filler was treated with an ethanol solution that contained only 3-methacryloyloxypropyltrimethoxysilane. In 5 cases, it was treated with solution containing a mixture of 3-methacryloyloxypropyltrimethoxysilane and one of the following hydrophobic fluoroalkyltrimethoxysilanes: trifluoropropyl-, nonafluorohexyl-, tridecafluorooctyl-, heptadecafluorodecyl-, and henicosafluorododecyl-trimethoxysilane. The tensile strength, after being immersed in water for 1800 days, of 2 of the experimental composites, whose pre-treatment regimen had included a fluoroalkyltrimethoxysilane, was significantly higher than that of the composite whose pre-treatment regimen had not included a fluoroalkyltrimethoxysilane. Moreover, there was no significant difference between the tensile strength of fresh samples of these 2 composites and the tensile strength of identically produced samples that had remained under water for 1800 days or that had been subjected to 30,000 cycles of thermal stress.