An increase in tumor-infiltrating lymphocytes after treatment is significantly associated with a poor response to neoadjuvant endocrine therapy for estrogen receptor-positive/HER2-negative breast cancers

BACKGROUND

The reason for the poor prognosis of estrogen receptor (ER) + /human epidermal growth factor receptor 2 (HER2)- breast cancer patients with high levels of tumor-infiltrating lymphocytes (TILs) is poorly understood. The association between TILs and response to neoadjuvant endocrine therapy (NET) was examined.

METHODS

We recruited 170 patients with ER + /HER2- breast cancer who were treated with preoperative endocrine monotherapy. TILs were evaluated before and after NET, and their changes were noted. Furthermore, T cell subtypes were examined using CD8 and FOXP3 immunohistochemical analyses. Neutrophil and lymphocyte counts in the peripheral blood were analyzed with reference to TIL levels or changes. Responders were defined as Ki67 expression levels ≤ 2.7% after treatment.

RESULTS

Post-treatment (p = 0.016), but not pre-treatment (p = 0.464), TIL levels were significantly associated with the response to NET. TIL levels increased significantly after treatment among non-responders (p = 0.001). FOXP3 + T cell counts increased significantly after treatment in patients with increased TILs (p = 0.035), but not in those without increased TILs (p = 0.281). Neutrophil counts decreased significantly after treatment in patients without increased TILs (p = 0.026), but not in patients with increased TILs (p = 0.312).

CONCLUSION

An increase in TILs after NET was significantly associated with a poor response to NET. Given that FOXP3 + T-cell counts increased, and neutrophil counts did not decrease in patients with increased TILs after NET, the induction of an immunosuppressive microenvironment was speculated to play a role in the inferior efficacy. These data might partially indicate the involvement of the immune response in the efficacy of endocrine therapy.

Abstract P5-12-02: Germline variants detected by next-generation sequencing-based multigene panel testing in patients with suspected hereditary breast cancer at a University Hospital in Japan

Background: The usefulness of prophylactic surgery and surveillance for hereditary breast cancer has been demonstrated, and germline testing for BRCA1 and BRCA2 had been covered by insurance since 2020 in Japan. In addition to BRCA1 and BRCA2, several other genes are also associated with an increased risk of developing breast cancer, such as PALB2, ATM, BARD1, CHEK2, PTEN, and TP53. Next-generation sequencing-enabled multigene panel tensing provides information about these gene variants at the same time, and at a low cost. Although germline testing of BRCA1 and BRCA2 has become widespread in Japan, multi-panel gene testing for germline variants has been conducted only in a limited number of facilities, partly due to the difficulty associated with dealing with the gene variant information obtained from the test. The aim of this study was to clarify the current status of multigene panel testing in our institute, and reveal the characteristics of the variants detected in patients with, or predisposed to, hereditary breast cancer. Methods: This retrospective study included 37 individuals who underwent next-generation sequencing-based multigene panel testing in order to investigate any inherited genetic variants due to a suspicion of hereditary breast cancer. Eighteen patients had a diagnosis of breast cancer with a family history of breast and/or ovarian cancer, nine patients had a diagnosis of breast cancer without family history of breast or ovarian cancer, and 10 patients had a family history of breast cancer but had not developed breast cancer themselves. Results: Utilizing mutigene panel testing, at least one alteration was found in 24 genes, and a total of 39 variants were found in the 37 patients. Of these 37 patients, nine (24.3%) had a pathogenic/likely pathogenic variant with or without other variants of uncertain significance (VUS), 15 (40.5%) had VUS, and 13 (35.1%) had negative genetic test results. Among the nine patients with pathogenic/likely pathogenic variants, seven had variants in either BRCA1 or BRCA2 (one BRCA1 pathogenic variant, five BRCA2 pathogenic variants, and one BRCA2 likely pathogenic variant), while the remaining positive results were attributed to other genes (one MLH1 pathogenic variant, and one SDHB pathogenic variant). VUS included BRCA1 and BRCA2, as well as other breast cancer-associated genes, such as ATM (n=2), CDH1 (n=2), NF1 (n=2), PALB2 (n=1), CHEK2 (n=1), NBN (n=1), and RAD51D (n=1). VUS also included other cancer syndrome-related genes, such as MLH1 (n=2), MUTYH (n=2), APC (n=1), and RET (n=1). Conclusion: Multigene panel tests in our institute revealed pathogenic/likely pathogenic variants in 24.3% of individuals who suspected hereditary breast cancer. As expected, multigene panel tests also revealed more VUS than pathogenic variants and 40.5% individuals were detected with VUS, which included many genes associated with hereditary breast cancer and other cancer syndromes, in addition to BRCA1 and BRCA2. Individuals with VUS will need to cope with new information if the interpretation of the variant changes in the future. We need to be aware of the characteristics and limitations of this type of panel testing, and to properly utilize the test results and information obtained for good quality patient care.

Citation Format: Yusa Atake, Masayuki Nagahashi, Haruka Kanaoka, Akira Hattori, Ayako Bun, Reiko Fukui, Hiromi Ozawa, Yukie Fujimoto, Tomoko Higuchi, Michiko Imamura, Keiko Murase, Yuichi Takatsuka, Mina Kashima, Chiho Okada, Chinatsu Kinjo, Mikako Miyata, Ayako Miyazaki, Mako Ueda, Hiroshi Tsubamoto, Hideaki Sawai, Yasuo Miyoshi. Germline variants detected by next-generation sequencing-based multigene panel testing in patients with suspected hereditary breast cancer at a University Hospital in Japan [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P5-12-02.

Abstract P4-07-26: Clinical impact of tumor infiltrating lymphocytes and neutrophil-lymphocyte ratio in estrogen receptor-positive/HER2-negative breast cancer patients with high 21-gene signature recurrence scores

Background: Many guidelines recommended multi-gene assays to determine an indication of postoperative chemotherapy for estrogen receptor-positive (ER+)/HER2-negative (HER2−) breast cancer patients. The 21-gene signature assay (Oncotype DX) is one such multi-gene assay and is recommended by the National Comprehensive Cancer Network (NCCN) Guidelines for Breast Cancer. The TAILORx trial determined that chemotherapy was indicated for patients with a high risk of recurrence score (high RS; ≧26) on the 21-gene signature assay. Although chemotherapy improves the prognosis of patients in the high-RS group, there is a subgroup of these patients who relapse after chemotherapy. It is expected that survival of this subgroup would improve with additional treatment, such as with CDK4/6 inhibitors. However, factors that predict relapse after chemotherapy in the high-risk patients are unknown. The aim of this study was to identify clinical factors that might predict relapse in the high-RS patients who underwent postoperative chemotherapy. To this end, we focused on tumor infiltrating lymphocytes (TILs) and neutrophil-lymphocyte ratio (NLR) in peripheral blood, and whether these factors are useful in predicting prognosis. Methods: A retrospective analysis of 48 patients who had the 21-gene signature assay performed postoperatively in our institute was performed. Of the 48 patients, 38 were in the low-RS group (1-25), and 10 were in the high-RS group (≧ 26). The cutoff values for TILs and NLR were set to 10% and 2.72, respectively, and the correlations with disease-free survival (DFS) were examined. Results: During the follow-up period (median, 1614 days), six out of 48 patients had distant metastases. Of these, four were in the low-RS and two were in the high-RS group. There was a significant correlation between TILs and RS (median and range of RS, 17.5, 6-47, for TILs-low; and 24, 15-66, for TILs-high; p = 0.0032), and TILs were higher in the high-RS group than in others. There was no correlation between NLR and RS (p = 0.215). In the RS-high patients, DFS was marginally (p = 0.0701) and significantly (p = 0.0253) shorter for TILs-low and NLR-high subgroups, respectively. In the high-RS group, none of six patients with high TILs relapsed, and two of four patients with low TILs relapsed. Conclusions: A subgroup of high-RS ER+/HER2− breast cancer patients with low TILs or high NLR may have a poorer prognosis. TILs are known to correlate with the effect of chemotherapy, and chemotherapy may be less effective in the low-TILs group, even with high-RS scores. TILs and NLR may be useful in determining the need for additional treatment in the high-RS group.

Citation Format: Haruka Kanaoka, Masayuki Nagahashi, Eri Ishikawa, Ayako Bun, Reiko Fukui, Hiromi Ozawa, Tomoko Higuchi, Keiko Natori, Michiko Imamura, Yuichi Takatsuka, Yasuo Miyoshi. Clinical impact of tumor infiltrating lymphocytes and neutrophil-lymphocyte ratio in estrogen receptor-positive/HER2-negative breast cancer patients with high 21-gene signature recurrence scores [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P4-07-26.

Abstract PS4-20: Low levels of interleukin-6 at baseline were significantly associated with improved overall survival of patients treated with eribulin for locally advanced or metastatic breast cancer

(Background)Eribulin, a non-taxane inhibitor of microtubule dynamics, is a unique chemotherapy agent for locally advanced or metastatic breast cancer (MBC). The treatment has been demonstrated to extend overall survival (OS) without extending progression-free survival (PFS). This effect seems to result from the suppression of epithelial-mesenchymal transition (EMT) and improvement of the hypoxic microenvironment by vascular normalization induced by eribulin, directly or indirectly. In a previous study, we identified that high absolute lymphocyte count (ALC) at the baseline was significantly associated with longer OS in the eribulin group, but not in the treatment of physician’s choice (TPC) group, in the phase III EMBRACE trial (Miyoshi et al., Breast Cancer, 2020). These results strongly suggest an association between eribulin efficacy and immune response. Therefore, we focused on serum levels of immune and inflammatory cytokines,which are expected to have greater utility as a predictive factor for eribulin than ALC. Interleukin (IL) 6, an inflammatory cytokine associated with cancerprogression, and soluble interleukin-2 receptor (sIL-2R), a receptor of IL-2 released from various immune cells including T cells, B cells, and natural killer cells, were selected for the investigation. (Patients and methods)A total of 44 patients treated with eribulin for MBC were recruited for the study. We examined the predictive values of IL-6 and sIL-2R in addition to the neutrophil-to-lymphocyte ratio (NLR) and ALC at baseline. The cutoff values of NLR and ALC were set at 3.0 and 1500/μL, respectively. We used the normal ranges of IL-6 (4.0 pg/mL) and sIL-2R (474 U/mL) as cutoff values. (Results)The OS of patients with low NLR (n=28) and high ALC (n=17) were significantly longer than that of patients with high NLR (n=16, p=0.0287) and low ALC (n=27, p=0.0234). There were no significant associations between PFS and NLR or ALC (p=0.0852 and p=0.2231, respectively). Patients with normal IL-6 levels (n=17) had significantly longer PFS (p=0.0023) and OS (p=0.0013) than those with elevated IL-6 levels (n=27). Regarding sIL-2R, patients with normal sIL-2R levels (n=18) had longer OS (p=0.0483) than those with elevated sIL-2R levels (n=26), but their PFS was similar (p=0.2435). Multivariate analysis showed that IL-6 levels were only significantly associated with OS (hazard ratio, 0.093; 95% confidence interval, 0.012-0.720; p=0.0106). There was no significant association between IL-6 levels and NLR or ALC. (Conclusion and discussion)Patients treated with eribulin demonstrated a significantly longer OS if their baseline IL-6 levels were within the normal range. This predictive efficacy for eribulin was more accurate than that of NLR or ALC. As there was no significant association between IL-6 levels and NLR or ALC, IL-6 appears to predict whether the tumor microenvironment is favorable or unfavorable for eribulin treatment, mediated through different mechanisms. Therefore, IL-6 levels may be useful for selecting patients who will benefit from the administration of eribulin in terms of improved OS.

Citation Format: Ayako Bun, Natsuko Inoue, Yoshimasa Miyagawa, Reiko Fukui, Yukie Fujimoto, Tomoko Higuchi, Atsushi Sata, Hiromi Ozawa, Michiko Imamura, Yasuo Miyoshi. Low levels of interleukin-6 at baseline were significantly associated with improved overall survival of patients treated with eribulin for locally advanced or metastatic breast cancer [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS4-20.

C-Reactive Protein and Absolute Lymphocyte Count Can Predict Overall Survival of Patients Treated With Eribulin

BACKGROUND/AIM

We investigated the efficacy of neutrophil-to-lymphocyte ratio (NLR), absolute lymphocyte count (ALC), and C-reactive protein (CRP) in predicting overall survival of metastatic breast cancer patients treated with eribulin.

PATIENTS AND METHODS

Overall, 74 patients treated with eribulin were enrolled and their baseline levels of NLR, ALC, and CRP retrieved. Cutoff values of NLR, ALC, and CRP were set at 3.0, 1500/μl, and 0.3 mg/dl, respectively. Overall survival (OS) was compared according to marker levels.

RESULTS

The OS of NLR-low, ALC-high, and CRP-low groups at baseline was significantly longer than that of NLR-high, ALC-low, and CRP-high groups (p=0.0027, p=0.0013, and p=0.0164, respectively). The combination of ALC and CRP was significantly associated with OS by multivariate analysis (p=0.048).

CONCLUSION

Baseline levels of NLR, ALC, and CRP were significantly associated with OS in patients treated with eribulin. The combination of ALC and CRP improved the predictive efficacy compared to individual markers.

Prognostic Significance of Neutrophil-to-lymphocyte Ratio in Luminal Breast Cancers With Low Levels of Tumour-infiltrating Lymphocytes

BACKGROUND/AIM

This study aimed to improve the prognostic significance of neutrophil-to-lymphocyte ratio (NLR) and tumour-infiltrating lymphocytes (TILs).

PATIENTS AND METHODS

In this retrospective study, NLR and TIL data from 677 operated breast cancer patients were analysed. The cut-off value of NLR was set at 2.72, and TIL levels were classified as low (<10%), intermediate (≥10 to <50%), and high (≥50%).

RESULTS

Recurrence-free survival (RFS) was significantly longer in patients with low NLR (n=459) than in those with high NLR (n=218) (p=0.0383). In ER-positive/HER2-negative and TIL-low breast cancers, there were significant associations between NLR levels and RFS (p=0.0129) or overall survival (OS) (p=0.0046). On multivariate analysis, NLR was a significant and independent factor for OS (hazard ratio=3.78; 95% confidence interval=1.21-14.17; p=0.022).

CONCLUSION

These data may be useful for predicting patient prognosis and understanding the clinical significance of immune status in breast cancers.

Association Between FOXP3/CD8 Lymphocyte Ratios and Tumor Infiltrating Lymphocyte Levels in Different Breast Cancer Subtypes

BACKGROUND/AIM

Patients with non-luminal breast cancer subtypes with high levels of tumor infiltrating lymphocytes (TILs) have better prognosis than those with luminal subtype. We evaluated the role of TILs according to the subtype.

MATERIALS AND METHODS

An immunohistochemical analysis of 139 breast cancer cases was conducted to calculate the FOXP3+/CD8+ T cell ratios and their relationships with TILs and disease-free survival (DFS) were evaluated.

RESULTS

FOXP3+/CD8+ T cell ratios were significantly associated with TIL levels only in luminal breast cancers (p=0.0001). Low FOXP3+/CD8+ T cell ratio was significantly associated with longer DFS (p=0.017). All luminal subtype patients with high TIL levels had high FOXP3+/CD8+ T cell ratios compared to only half of non-luminal subtype patients with high TIL levels.

CONCLUSION

High FOXP3+/CD8+ T cell ratios in breast cancers may partly explain the worse prognosis of luminal breast cancers, but not that of non-luminal breast cancers with high TIL levels.

Abstract P3-08-49: Baseline neutrophil-to-lymphocyte ratio and C-reactive protein predict efficacy of bevacizumab plus paclitaxel therapy for locally advanced or metastatic breast cancer

Background Vascular endothelial growth factor (VEGF) is a key player in angiogenesis, and bevacizumab, a humanized monoclonal antibody against VEGF-A, is already utilized in daily clinical practice coupled with chemotherapy for locally advanced and metastatic breast cancers (ABC). Although the impact of bevacizumab plus paclitaxel therapy on PFS was prominent, no OS benefit has been demonstrated so far. Identification of a robust biomarker for bevacizumab therapy in terms of benefit on OS is a critical issue. Since VEGF modulates various functions of cancer immunity, direct inhibition of VEGF, in addition to vascular normalization by bevacizumab may lead to improvement of immune microenvironment, resulting in favorable prognosis in patients. On the basis of this aspect, predictive efficacy of peripheral immune related parameters were investigated in patients treated with bevacizumab plus paclitaxel. Method A total of 182 patients with locally advanced and metastatic breast cancers treated with bevacizumab plus paclitaxel were retrospectively recruited from three institutes. We measured neutrophil-to-lymphocyte ratio (NLR), absolute lymphocyte count (ALC), and c-reactive protein (CRP) in the peripheral blood taken at baseline (the same day just before start of 1st treatment). Bevacizumab 10 mg/kg on days 1 and 15 and paclitaxel 80 or 90 mg/m2 on day 1, 8, and 15 of each 28-day cycle were administered intravenously. The cut-off values of NLR, ALC, and CRP were set at 3, 1500/μL, and 1.0mg/dL, respectively and baseline values of these factors were measured. Results We divided the patients into NLR-high (n=101) and -low (n=81); CRP-high (n=62) and -low (n=89). The progression-free survival (PFS) of patients with NLR-low was significantly longer than that of patients with NLR-high (median, 12.6 vs. 7.2 months; hazard ratio (HR), 0.47; 95% confidence interval (CI), 0.31-0.70; p=0.0002). In addition, OS of patients with NLR-low was significantly better than those with -high (22.2 vs. 13.5 months; HR, 0.55; 95% CI, 0.38-0.80; p=0.0017). Similarly, improved PFS and OS were recognized in patients with CRP-low as compared with -high (HR, 0.42; 95% CI, 0.27-0.66; p&lt;0.0001 and HR, 0.38; 95% CI, 0.25-0.59; p&lt;0.0001, respectively). By multivariable analysis, both NLR-low (HR, 0.56; 95% CI, 0.33-0.91; p=0.0198) and CRP-low (HR, 0.50; 0.32-0.79; p=0.003) were significantly and independently associated with longer PFS. As for OS, both NLR (HR, 0.61; 95% CI, 0.38-0.97; p=0.0368) and CRP (HR, 0.39; 95% CI, 0.24-0.63; p=0.0001) were significant and independent predictors by multivariable analysis.Discussion and conclusion Low levels of NLR and CRP at baseline were found to be significantly associated with improved PFS as well as OS in patients treated with bevacizumab plus paclitaxel. Although the detailed mechanisms are currently unknown, patients with low NLR or CRP at baseline may represent a favorable immune microenvironment which could be linked with an increased treatment efficacy. NLR and CRP levels at baseline seem to be useful for selecting patients who could benefit in terms of OS from bevacizumab treatment.

Citation Format: Hiromi Ozawa, Yoshimasa Miyagawa, Ayako Yanai, Takehiro Yanagawa, Jyunichi Inatome, Chiyomi Egawa, Arisa Nishimukai, Kaori Takamoto, Takashi Morimoto, Atsushi Sata, Reiko Fukui, Ayako Bun, Tomoko Higuchi, Yukie Fujimoto, Michiko Imamura, Yasuo Miyoshi. Baseline neutrophil-to-lymphocyte ratio and C-reactive protein predict efficacy of bevacizumab plus paclitaxel therapy for locally advanced or metastatic breast cancer [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P3-08-49.

Abstract P3-08-30: Low levels of metabolic tumor volume at baseline significantly associated with longer progression-free survival in patients with locally advanced or metastatic breast cancer treated with endocrine therapies

Background Endocrine therapy is an essential treatment choice for patients with estrogen receptor (ER)-positive and human epidermal growth factor receptor 2 (HER2)-negative locally advanced and metastatic breast cancers. Although patients with non-visceral metastasis or with favorable efficacy induced by prior endocrine therapy, are reported to be associated with a longer duration of endocrine therapy, predictive markers have yet to be established. In general, breast cancers with low proliferative activity and small tumor burden seem to obtain favorable efficacy induced by endocrine therapy. Metabolic tumor volume (MTV) on fluorodeoxyglucose-positron emission tomography (FDG-PET) examination measures uptake activity of glucose in tumor cells, which represents tumor aggressiveness, and tumor volume. Thus, using MTV as a metabolic parameter for both proliferative activity and tumor burden, we evaluated the predictive usefulness of MTV for treatment efficacy of endocrine therapy.MethodA total of 83 patients treated with endocrine therapy for locally advanced and metastatic breast cancers, treated with an aromatase inhibitor (AI; n=39) or fulvestrant (Ful; n=44), examined by FDG-PET before start of treatment, were constitutively recruited in this retrospective study. The treatment lines were as follows; 1st, n=46; 2nd, n=22; 3rdor more, n=15. The maximum value of the standard uptake value (SUV, regional radioactivity concentration (Bq/mL)/injected dose (Bq)/patient weight (g)) in the volume of interest (VOI) was defined as the SUVmax. Total volume of voxels of ≥40% of the SUVmax in the VOI was defined as the MTV. The cut-off value of MTV was defined at 45 and the relationships between MTV and progression-free survival (PFS) was calculated.ResultsPFS of patients treated with Ful (median, 19.0 months) was marginally favorable than those with AI (median, 9.8 months; p=0.084). In all participants, PFS of patients with low levels of MTV (n=29; median, 23.6 months) was significantly longer than those with high levels (n=54; median, 10.0 months; p=0.0124). The association between low levels of MTV and longer PFS was significantly (p=0.0369) and marginally (p=0.0715) recognized in Ful and AI, respectively. Similarly, association between MTV and PFS seems to be consistent in subgroups in visceral or non-visceral metastasis, de novo or recurrence, and treatment lines.Discussion and conclusionIn the present study, we demonstrated that low levels of MTV at baseline are significantly associated with longer PFS for patients treated with AI or Ful. MTV seems to be a predictor for the efficacy of endocrine therapy by evaluating both tumor aggressiveness and tumor volume. This data may be useful in selecting patients who could benefit from endocrine therapy with non-invasive method.

Citation Format: Reiko Fukui, Tomoko Higuchi, Yukie Fujimoto, Atsushi Sata, Ayako Bun, Hiromi Ozawa, Hiromi Ozawa, Yoshimasa Miyagawa, Michiko Imamura, Kazuhiro Kitajima, Yasuo Miyoshi. Low levels of metabolic tumor volume at baseline significantly associated with longer progression-free survival in patients with locally advanced or metastatic breast cancer treated with endocrine therapies [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P3-08-30.

Baseline neutrophil-to-lymphocyte ratio and c-reactive protein predict efficacy of treatment with bevacizumab plus paclitaxel for locally advanced or metastatic breast cancer

The effect of bevacizumab plus paclitaxel therapy on progression-free survival (PFS) is prominent; however, no overall survival (OS) benefit has been demonstrated. Our aim was to study the predictive efficacy of peripheral immune-related parameters, neutrophil-to-lymphocyte ratio (NLR), absolute lymphocyte count (ALC), and c-reactive protein (CRP) in locally advanced and metastatic breast cancers. A total of 179 patients treated with bevacizumab plus paclitaxel were recruited from three institutes in the test cohort. The cut-off values of NLR, ALC, and CRP were set at 3, 1500/μL, and 1.0 mg/dL, respectively, and baseline values of these factors were measured. The PFS of patients with NLR-low was significantly longer than that of patients with -high (median, 12.6 vs. 7.2 months; hazard ratio (HR), 0.48, 95% confidence interval (95% CI), 0.31–0.73; p = 0.0004). OS of patients with NLR-low was significantly better than those with-high (22.2 vs. 13.5 months; HR, 0.57, 95% CI, 0.39–0.83; p = 0.0032). Similarly, improved PFS and OS were recognized in patients with CRP-low as compared with patients with -high (HR, 0.44, 95% CI, 0.28–0.68; p = 0.0001 and HR, 0.39, 95% CI, 0.26–0.61, p < 0.0001, respectively). In the validation cohort from two institutes (n = 57), similar significant improvements in PFS and OS were confirmed for patients with NLR-low (p = 0.0344 and p = 0.0233, respectively) and CRP-low groups (p < 0.0001 and p = 0.0001, respectively). Low levels of NLR and CRP at baseline were significantly associated with improved prognosis in patients treated with bevacizumab plus paclitaxel.

A Single-centre, Retrospective, Observational Analysis of Fulvestrant for Recurrent/metastatic Breast Cancer According to Metastatic Site

BACKGROUND/AIM

Factors influencing fulvestrant efficacy may be useful in selecting the optimal treatment regimen for postmenopausal Japanese women with metastatic/recurrent HR-positive, HER2-negative breast cancer.

PATIENTS AND METHODS

We retrospectively evaluated progression-free and overall survival (PFS and OS) in 100 fulvestrant-treated patients according to metastatic site.

RESULTS

Median PFS was significantly better in patients with non-visceral (bone and regional metastases; 22.8 months) vs. visceral metastasis (lung, liver, and other organs; 8.2 months; p=0.024), although median OS did not differ (p=0.922). Median PFS in patients with lung metastasis (20.8 months) and non-visceral metastasis (22.8 months) were comparable; patients with liver metastasis (6.1 months) and other organ metastases (3.7 months) had worse prognoses.

CONCLUSION

Patients with non-visceral metastases had a better prognosis than those with visceral metastases. Fulvestrant induced a longer PFS in patients with non-visceral metastasis, and also in those with lung metastasis without liver or other organ involvement.

Prognostic significance of tumor-infiltrating lymphocytes may differ depending on Ki67 expression levels in estrogen receptor-positive/HER2-negative operated breast cancers

BACKGROUND

The prognostic significance of tumor-infiltrating lymphocytes (TILs) has been established in breast cancers with estrogen receptor (ER)-negative and human epithelial growth factor receptor 2 (HER2)-negative or HER2-positive subtypes; however, its utility concerning the ER + /HER2 - subtype remains unclear.

METHODS

We evaluated the prognostic value of TILs by analyzing 717 invasive breast cancer operation cases. TILs were classified into three groups based on the proportion of area within the tumor: low ( < 10%), intermediate (10-50%), and high ( > 50%). Disease-free survival (DFS) and overall survival (OS) were calculated according to TIL levels.

RESULTS

Although there was no significant association between TIL levels and DFS or OS in all patients, high TILs were significantly associated with favorable DFS in Ki67-high (n = 238, p = 0.035) but not in Ki67-low (n = 470, p = 0.46) breast cancers. Multivariable analysis showed that high TILs were a significant and independent factor for DFS (HR 0.34; 95% CI 0.10-0.87; p = 0.023) among the Ki67-high group. In the ER + /HER2 - subtype, high-TILs showed favorable DFS in the Ki67-high group, although this was not statistically significant (p = 0.48); in contrast, unfavorable DFS was observed in the Ki67-low group (p = 0.027).

CONCLUSIONS

In Ki67-high breast cancers, high TILs were associated with favorable DFS, irrespective of subtype, but increasing TIL levels correlated with worse DFS in the Ki67-low group with the ER + /HER2 - subtype. These results highlight variation in TIL prognostic significance between Ki67-high and -low breast cancers, particularly for the ER + /HER2 - subtype.

Significance of Metabolic Tumor Volume at Baseline and Reduction of Mean Standardized Uptake Value in 18F-FDG-PET/CT Imaging for Predicting Pathological Complete Response in Breast Cancers Treated with Preoperative Chemotherapy

Background

The usefulness of ¹⁸F-fluorodeoxyglucose-positron emission tomography/computed tomography for evaluating the treatment efficacy of breast cancers is well-established; however, the predictive values of parameters such as metabolic tumor volume (MTV) and total lesion glycolysis (TLG) remain unknown.

Methods

This study examined 199 breast cancers treated with primary systemic chemotherapy (PSC) followed by operation, and determined the values of maximum standardized uptake value (SUV_max), peak SUV (SUV_peak), mean SUV (SUV_mean), MTV, and TLG at baseline. Among these cases, data on early changes in these metabolic parameters in 70 breast cancers were also assessed.

Results

A pathological complete response (pCR) was achieved in 64 breast cancers. Breast cancers with low MTV at baseline had a significantly higher pCR rate than breast cancers with high MTV (47.9% vs. 23.4%; p = 0.0005). High reduction rates (∆) of SUV_max (p = 0.0001), SUV_peak (p = 0.0001), and SUV_mean (p < 0.0001) resulted in an increased pCR compared with those for low ∆. The pCR rate was highest for the combination of low MTV and high ∆SUV_mean (86.7%), and lowest for high MTV and low ∆SUV_mean (15.4%); the remaining combinations were intermediate (58.6%; p < 0.0001). The combination of low MTV at baseline and high ∆SUV_mean was a significant and independent predictor for pCR (odds ratio 28.63; 95% confidence interval 1.94–422.42; p = 0.0146) in multivariable analysis.

Conclusions

Low levels of MTV at baseline and a high reduction of SUV_mean after PSC was significantly associated with pCR. These findings suggest the usefulness of these metabolic parameters for predicting the treatment efficacy of breast cancers.

Electronic supplementary material

The online version of this article (10.1245/s10434-019-07325-8) contains supplementary material, which is available to authorized users.

Effects of Nutrition Therapy in Older Stroke Patients Undergoing Rehabilitation: A Systematic Review and Meta-Analysis

OBJECTIVE

To systematically review evidence on the effects of nutrition therapy in older stroke patients undergoing rehabilitation and identify its effectiveness using meta-analysis.

METHODS

PubMed (MEDLINE), EMBASE (via Dialog), Cochrane Central Register of Controlled Trial, World Health Organization International Clinical Trials Registry Platform and Ichu-shi Web were searched for relevant articles. Randomized controlled trials investigating the effects of nutrition therapy compared to control interventions in older stroke patients undergoing rehabilitation were considered eligible. The primary outcome was activities of daily living (ADL), and secondary outcomes were all-cause mortality, infections, pneumonia incidence, disability level, walking ability, fall, stroke recurrence, and quality of life. The risk of bias of each trial was assessed using the Cochrane Collaboration Tool, and the quality of the body of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach.

RESULTS

Eight randomized controlled trials with a total of 5484 participants were included in the meta-analysis. The meta-analysis for ADL showed no significant effects (mean difference, 4.16; 95% confidence interval [CI], -0.88 to 9.20; I2=53%, low-quality evidence). The meta-analyses for secondary outcomes revealed a significant effect of reduced infections (risk ratio, 0.65; 95% CI, 0.51 to 0.84; I2=0%; low-quality evidence), with no significant effects on the other outcomes.

CONCLUSION

Nutrition therapy had no statistically significant effect on ADL. However, it reduced the incidence of infections. More high-quality trials are warranted to clarify the effects of nutrition therapy in older stroke patients undergoing rehabilitation.

Safety for Repeat Lumpectomy Without Radiotherapy for Ipsilateral Breast Tumor Recurrence

BACKGROUND

There is little information on the local recurrence risk of patients who undergo repeat lumpectomy without radiotherapy after salvage surgery for ipsilateral breast tumor recurrence (IBTR).

PATIENTS AND METHODS

Sixty-five patients who underwent repeat lumpectomy without radiotherapy after IBTR were retrospectively analyzed. The risk factors of second IBTR, including the breast cancer subtype of IBTR defined by the estrogen receptor (ER) and HER2 status, were assessed.

RESULTS

The median follow-up period was 62 months. The 5-year second IBTR-free survival rate was 83%. Patients with the ER-positive/HER2-negative subtype of IBTR had a significantly better second IBTR-free survival rate than those with other subtypes of IBTR (88% vs. 75%, respectively, p=0.02). Multivariate analysis revealed that the breast cancer subtype of IBTR was a significantly independent predictive factor of second IBTR-free survival (p=0.003). A low-risk group for second IBTR, defined by the breast cancer subtype of IBTR and margin status of primary surgery, was detected (5-year second IBTR-free survival rate: 100%).

CONCLUSION

Patients in the low-risk group defined by the breast cancer subtype of IBTR and margin status of primary surgery could safely undergo repeat lumpectomy without radiotherapy for IBTR.

Combination of Recreational Soccer and Caloric Restricted Diet Reduces Markers of Protein Catabolism and Cardiovascular Risk in Patients with Type 2 Diabetes

BACKGROUND

Moderate calorie-restricted diets and exercise training prevent loss of lean mass and cardiovascular risk. Because adherence to routine exercise recommendation is generally poor, we utilized recreational soccer training as a novel therapeutic exercise intervention in type 2 diabetes (T2D) patients.

OBJECTIVE

We compared the effects of acute and chronic soccer training plus calorie-restricted diet on protein catabolism and cardiovascular risk markers in T2D.

DESIGN, SETTING AND SUBJECTS

Fifty-one T2D patients (61.1±6.4 years, 29 females: 22 males) were randomly allocated to the soccer+diet-group (SDG) or to the diet-group (DG). The 40-min soccer sessions were held 3 times per week for 12 weeks.

RESULTS

Nineteen participants attended 100% of scheduled soccer sessions, and none suffered any injuries. The SDG group showed higher levels of growth hormone (GH), free fatty acids and ammonia compared with DG. After 12 weeks, insulin-like growth factor binding protein (IGFPB)-3 and glucose levels were lower in SDG, whereas insulin-like growth factor (IGF)-1/ IGFBP-3 ratio increased in both groups. After the last training session, an increase in IGF-1/IGFBP-3 and attenuation in ammonia levels were suggestive of lower muscle protein catabolism.

CONCLUSIONS

Recreational soccer training was popular and safe, and was associated with decreased plasma glucose and IGFBP-3 levels, decreased ammoniagenesis, and increased lipolytic activity and IGF-1/IGFBP-3 ratio, all indicative of attenuated catabolism.

Positive effects of football on fitness, lipid profile, and insulin resistance in Brazilian patients with type 2 diabetes

We evaluated the effects of recreational football training combined with calorie-restricted diet (football + diet) vs calorie-restricted diet alone (diet) on aerobic fitness, lipid profile, and insulin resistance indicators in type 2 diabetes (T2D) patients. Forty-four T2D patients aged 48-68 years (27 females, 17 males) were randomly allocated to the football + diet group (FDG; n = 22) or to the diet group (DG; n = 22), of whom 19 FDG and 15 DG subjects completed the study. The football training was performed for 3 × 40 min/week for 12 weeks. Dual-energy X-ray absorptiometry scanning, treadmill testing, and fasting blood samplings were performed pre and post-intervention. After 12 weeks, maximal oxygen uptake (VO₂max ) was elevated (P < 0.05) by 10 ± 4% in FDG but not in DG (-3 ± 4%, P < 0.05). After 12 weeks, reductions in blood triglycerides (0.4 ± 0.1 mmol/L), total cholesterol (0.6 ± 0.2 mmol/L), low-density lipoprotein, and very low-density lipoprotein levels were observed only in FDG. Fat mass decreased (P < 0.05) by 3.4 ± 0.4 kg in FDG and 3.7 ± 0.4 kg in DG. The lower (P < 0.05) glucagon and homeostatic model assessment of insulin resistance indicated an improvement in insulin sensitivity in FDG. In conclusion, football combined with restricted diet was effective in enhancing VO₂max , reducing total cholesterol and triglycerides, and increasing insulin sensitivity, potentially providing better tools for the prevention of T2D complications than diet alone.

62 EFFECTS OF VARYING GLUTATHIONE CONCENTRATIONS IN SEMEN EXTENDER ON THE QUALITY OF FROZEN–THAWED CANINE SPERM

Trans-cervical insemination (TCI) with cryopreserved semen offers a potentially effective approach for breeding canids with specific genetic traits, such as guide dogs for the blind. However, there are technical difficulties in canine sperm cryopreservation, such as the composition of semen extender. The aim of this study was to evaluate the effects of glutathione (GSH) as an antioxidant in the semen extender to improve the quality of frozen-thawed dog sperm. A Tris-egg yolk-citrate extender containing 15.7 mg mL–1 of TRIS, 8.8 mg mL–1 of citric acid, 14.1 mg mL–1 of lactose, 25.4 mg mL–1 of raffinose, 1% (vol/vol) antibiotics, and 20% (vol/vol) egg yolk in ultra-pure water was used as the base medium. Twelve ejaculates were collected from 7 dogs. Each ejaculate was divided into 2 to 5 aliquots and extended with base extender supplemented with 0, 2.5, 5, 7.5, and 10 mM GSH as first dilution. The extended semen was equilibrated for 3 h at 4°C. An equal volume of second extender was added to obtain a final concentration of 6.5% glycerol and sperm per milliliter. The sperm samples were loaded in straws and frozen at 6 cm above the surface of LN2 for 15 min in a styrene foam box and plunged into the LN2. The frozen semen was thawed for evaluation. The motility of sperm was estimated with a phase-contrast microscope and the motile patterns were classified into the following grades: progressively motile at a high speed (+++), progressively motile at a moderate and low speed (++), motile without progression (+), and immotile (–). Then, the sperm motility index (SMI) was determined from the following formula as described previously (Iritani et al., 1975), with some modifications: the percentage of (+++) sperm + the percentage of (++) sperm × 0.75 + the percentage of (+) sperm × 0.5. Sperm motility and the SMI were determined at 0, 1, 2, 3, 4, 12, and 24 h after thawing. Acrosome status was evaluated at 4 h after thawing. Lipid peroxidation (LP) levels at 0 and 12 h after thawing were used to examine the antioxidant ability of GSH. Trans-cervical insemination was carried out on 5 bitches to evaluate the fertility of GSH-treated sperm. The TCI were performed nonsurgically with a laparoscope and deposited 2 mL of semen through a catheter. Each bitch was inseminated 1 to 2 times during oestrus. Data were analysed using ANOVA with the Tukey-Kramer method. We found that the rate of (+++) sperm in the 5 mM GSH group was higher than that in the 0 mM group from 1 to 24 h after thawing (P < 0.05). The SMI was higher in the 5 and 7.5 mM GSH groups than in the 0 mM group (P < 0.05). There were no significant differences in the control and 2.5 and 10 mM GSH groups. Long-term survival was increased in the 5 mM GSH group. Acrosome integrity was higher in the GSH-treated group. The level of LP was lower in the GSH-treated groups at 0 h after thawing (P < 0.05). Trans-cervical insemination with the 5 mM GSH-treated semen resulted in the delivery of 5 pups from 2 bitches. These results indicate that the cryopreservation with 5 mM GSH can improve the motility, viability, and fertility of frozen-thawed canine sperm by its antioxidant effects on the sperm membrane.

Improved delineation of arteries in the posterior fossa of the brain by model-based iterative reconstruction in volume-rendered 3D CT angiography

BACKGROUND AND PURPOSE

Improved CTA delineation of arteries and unruptured aneurysms is clinically desired in the posterior fossa. We present a novel model-based iterative reconstruction that models system statistics and optics to improve CT image quality. We investigated the utility of MBIR for improving delineation of arteries in the posterior fossa on 3D brain CTA.

MATERIALS AND METHODS

Using filtered back-projection with a standard kernel and MBIR, we reconstructed axial images of 0.625-mm thickness of 28 consecutive patients (14 men; mean age, 58.6 ± 14.6 years) who underwent 64-detector brain CTA. We placed regions of interest on the axial images, measured the mean CT value in the basilar artery and the value and SD in the pons and bilateral cerebellar hemispheres, and calculated the contrast-to-noise ratio of the brain arteries in the posterior fossa. Using volume-rendered CTA and a 4-point scale, 2 radiologists independently graded delineation of the BA, bilateral vertebral artery, superior cerebellar artery, and anterior and posterior inferior cerebellar arteries. We compared the results between FBP and MBIR by using paired t and Wilcoxon signed-rank tests.

RESULTS

Compared with FBP, MBIR significantly improved the contrast-to-noise ratio (P < .0001) and subjective delineation of all arteries in the posterior fossa except the BA (VA, SCA, AICA, and PICA; P < .05 for all). The mean visual score by MBIR was 3.0 or higher for all those arteries except the AICA assessed by reader 1 (2.6 ± 0.7).

CONCLUSIONS

With 3D brain CTA, contrast-to-noise ratio and arterial delineation of the VA, SCA, AICA, and PICA in the posterior fossa are better with MBIR than FBP.

Metastases-related genes in the classification of liver and peritoneal metastasis in human gastric cancer

INTRODUCTION

With the aim of identifying metastases-related genes in gastric cancer, we performed a broad analysis of differential gene expression between low-metastatic parental cell lines and established highly metastatic sublines.

MATERIALS AND METHODS

We established novel cell lines, AZ-H5c, NUGC-3H5, and TMK-1H7, with a high potential of liver metastasis, and AZ-P7a, NUGC-3P4T, and TMK-1P4a, with a high potential of peritoneal metastasis. These cell lines were derived from low-metastatic parental AZ-521, NUGC-3, and TMK-1 cell lines, respectively. Furthermore, to investigate different levels of gene expression implicated in metastatic potentials in gastric cancer, we investigated approximately 2000 expressed genes in each cell line using a DNA microarray.

RESULTS

Varieties of genes were up-regulated or down-regulated in highly metastatic liver and peritoneal cell lines. Fifty-eight genes, including the transferrin receptor, ras-related rho, and osteopontin, and 22 genes, including apolipoprotein E and inhibin A-submit, were up-regulated and down-regulated in two or three liver metastatic sublines. On the other hand, 19 genes, the transferrin receptor, c-fos, and RANTES, and 26 genes, including MAC25, PISSLRE, and RNA polymerase, were up-regulated and down-regulated in two or three peritoneal metastatic sublines.

CONCLUSION

How gene expression is implicated in gastric cancer metastasis has never been thoroughly explained, and further studies are necessary to understand the involvement of genes in cancer metastasis more thoroughly. We hope that our highly metastatic liver and peritoneal experimental models are helpful for further study and gene therapy of human gastric cancer.

High IL-6 synthesis in cultured fibroblasts isolated from radicular cysts

OBJECTIVE

Inflammatory cytokines have been reported to be related with inflammation and expansion of jaw cysts. In this study, to examine the relationship between radicular cysts and inflammatory cytokines, it was found that there was notable unique evidence on cytokine synthesis from fibroblasts isolated from radicular cysts.

METHODS

The expression of such cytokines, namely, interleukin-1beta, IL-1beta, IL-6, IL-8, IL-10, tumour necrosis factor-alpha (TNF-alpha), interferon-gamma (IFN-gamma), transforming growth factor-beta1 (TGF-beta1), and granulocyte-macrophage colony-stimulating (GM-CSF) mRNA, in nine radicular cysts was examined and compared with that detected in six specimens of healthy gingival mucosa. Furthermore, separating all fibroblasts from their respective radicular cysts, healthy gingival mucosa, and healthy periodontal ligaments, these fibroblast groups were cultured without stimulators and a supernatant for each was obtained to analyse IL-1beta, IL-6, IL-8, TNF-alpha, and IFN-gamma by ELISA.

RESULTS

Differences between radicular cysts and healthy gingival mucosa were not clearly shown by the expression of cytokine mRNA. Analysing inflammatory cytokine synthesis in fibroblast groups from these three kinds of tissues, surprisingly, the levels of IL-6 mRNA and protein were recognised to be higher in fibroblasts of radicular cysts than in those of control tissues by ELISA and a real-time RT-PCR. Significant differences in the cultured supernatants of these fibroblast groups were not recognised in the release of IL-1beta, IL-8, TNF-alpha, and IFN-gamma by ELISA.

CONCLUSIONS

From these results, it was suggested that fibroblasts inducing IL-6 production might play important roles in the expansion of radicular cysts. It is considered that fibroblasts around radicular cysts may lead to high IL-6 synthesis over time in chronic inflammation.

Beraprost sodium regulates cell cycle in vascular smooth muscle cells through cAMP signaling by preventing down-regulation of p27(Kip1)

OBJECTIVE

Beraprost sodium (BPS), a prostacyclin (PGI(2)) analogue, has been reported to exhibit beneficial effects on atherosclerosis in both human and animal models. To clarify the underlying mechanism, we investigated the effects of BPS on neointimal formation after balloon injury in the canine coronary artery. Furthermore, we determined its anti-atherosclerotic effects in cultured smooth muscle cells (SMCs).

METHODS

Adult beagle dogs (10-12 kg) were fed on a high-cholesterol diet (10 g/day) and underwent balloon-denudation of the coronary artery. The dogs were divided into two groups: a BPS-treated group (20 microg/kg per day) and a control group. Twenty-eight days after injury, the dogs were killed and the coronary arteries were examined morphometrically. Three days after injury, the proliferative activity in the medial layer of the coronary artery was evaluated by 5-bromo-2'-deoxyuridine (BrdU) incorporation, and p27(Kip1), a cyclin-dependent kinase (cdk) inhibitor, expression was examined by immunohistochemistry. We also examined the effects of BPS on SMC proliferation based on BrdU incorporation and cell cycle analysis. In addition, p27(Kip1) regulation was evaluated in primary-cultured SMCs.

RESULTS

BPS administration decreased the intima/media ratio (I/M) by 88% in the control group. Three days after injury, BPS attenuated the proliferation rate of the cells in the media of the coronary artery by 35%, and maintained p27(Kip1) expression, which declined in the control cells. In the cultured proliferating SMC, BPS prevented the down-regulation of p27(Kip1). The 8-bromo-cyclic adenosine monophosphate (8-br-cAMP), a cAMP analogue, had similar actions as BPS in the regulation of p27(Kip1). The proliferation of cultured SMC was inhibited in a dose-dependent manner, and cell cycle arrest in the G1 phase was induced by BPS.

CONCLUSIONS

Our data suggest that BPS inhibits neointimal formation after balloon denudation in the coronary artery through its inhibitory effect on SMC proliferation by preventing p27(Kip1) down-regulation.

Tubular adenoma of the breast in a 73-year-old woman

A 73-year-old woman presenting with a right breast mass is described. The patient underwent lumpectomy under a diagnosis of breast cancer. However, histopathologically the surgical specimen was tubular adenoma of the breast. This is a rare benign tumor that is difficult to differentiate from breast cancer clinically, especially in elderly patients. We describe two reported cases of tubular adenoma in patients older than 65-years in Japan, as well as the present case.

Adenosquamous carcinoma of the colorectum: report of two cases

Adenosquamous carcinomas of the colorectum are rare neoplasms. Our experience with two cases is presented in this paper. One patient, who complained of bloody stool, was found to have adenocarcinoma in the sigmoid colon. He received a laparoscopy-assisted sigmoidectomy. The histological examination revealed that the tumor was adenosquamous carcinoma. To date, he has survived six months post operatively without evidence of recurrence. The other patient, who complained of anal bleeding, was found to have rectal adenocarcinoma and received a low anterior resection. Histological examination revealed that the tumor was an adenosquamous carcinoma. He remains alive, with no evidence of recurrence, nine years post operatively. Both cases showed paracolic lymph node metastasis. Because of its very low incidence, the histogenesis, malignancy and prognosis of this disease remain unclear. Thus, further clinical and histological study of this disease entity is required.

Increased migration in late G(1) phase in cultured smooth muscle cells

Migration and proliferation of smooth muscle cells (SMC) contribute to neointimal formation after arterial injury. However, the relation between migration and proliferation in these cells is obscure. To discriminate between migration and proliferation, we employed a migration assay of SMC at different phases of the cell cycle. Serum-deprived SMC were synchronized in different phases of the cell cycle by addition of serum for various periods of time. Migration induced by platelet-derived growth factor B-chain homodimer was maximal in SMC that were predominantly in the late G(1) (G(1b)) phase. In addition, in nonsynchronized SMC, 65-75% of SMC that had migrated were in the G(1b) phase. Phosphorylated myosin light chain was enriched around the cell periphery in SMC in the G(1b) phase compared with SMC in the other cell cycle phases. Interestingly, the Triton X-100-insoluble fraction of myosin was remarkably decreased in G(1b)-enriched SMC. These findings suggest that migratory activity of SMC may be coupled with the G(1b) phase. The phosphorylation and retention of myosin might explain some of the properties responsible for increased migration.

Activation of Ca2+-activated K+ channels in human myometrium by nitric oxide

To investigate the mechanism of human uterine smooth muscle relaxation, the activation of Ca2+-activated K+ channels in cultured myometrial cells obtained from human pregnant myometrium at term by nitric oxide was evaluated at the single cell level using the patch-clamp technique. The open probability of the K+ channel after the addition of 3 x 10(-3) M isosorbide dinitrate, a nitric oxide donor (0.116 +/- 0.048) was significantly higher than that before the addition (0.059 +/- 0.032; n = 9, p < 0.01). In myometrial cells pretreated with lipopolysaccharide, activation of K+ channels was also noted after the addition of L-arginine (10(-4) M; open probability increased from 0.179 +/- 0.076 to 0.380 +/- 0.105, n = 9, p < 0.01: 10(-3) M; open probability increased from 0.073 +/- 0.050 to 0.242 +/- 0.098, n = 12, p < 0.01). Either 10(-3) M N-nitro-L-arginine-methyl-ester, an inhibitor of nitric oxide synthase, or 10(-6) M methylene blue, an inhibitor of guanylate cyclase, abolished activation of the K+ channel by 10(-3) M L-arginine in pretreated myometrial cells with lipopolysaccharide. Application of 10(-3) M L-arginine to the intracellular surface of an excised inside-out patch in the myometrial cells pretreated with lipopolysaccharide failed to increase Ca2+-activated K+ channel activity, suggesting that the activation was mediated by intracellular messengers. These results indicate that nitric oxide should control human myometrial relaxation during pregnancy via activation of Ca2+-activated K+ channels.

A patient with cyclic neutropenia complicated by severe persistent neutropenia successfully delivered a healthy baby

We describe a 24-year-old pregnant woman complicated by cyclic neutropenia (CN), who was successfully treated with granulocyte-colony stimulating factor (G-CSF). Her white blood cell (WBC) and neutrophil count fluctuated from 2,600 to 4,600/microl, and 26 to 2,530/microl, respectively. The peak neutrophil count gradually decreased as pregnancy advanced, resulting in the disappearance of its cyclicity. At 39 weeks of pregnancy when the neutrophil count became 84/microl, the patient was started on G-CSF and her neutrophil count increased to 1,550/microl on the fourth day after delivery. She delivered a healthy baby without any complications at 39 weeks of pregnancy.

Effect of temperature on the incubation period and leaf colonization in bacterial blight of anthurium

ABSTRACT Effect of temperature on leaf colonization in anthurium blight was studied using a bioluminescent strain of Xanthomonas campestris pv. dieffenbachiae. In a susceptible cultivar, colonization of leaf tissues (monitored by detection of bioluminescence) and symptom development (assessed visually) advanced rapidly at higher temperatures. For a susceptible cultivar, there was a linear relationship between degree-days and percent leaf area colonized by the pathogen, indicating that leaf colonization in a susceptible cultivar was a direct function of the cumulative effect of temperature. The degree-day intercept of the regression line represented the time from inoculation to detection of bioluminescence, and the slope indicated the increase of leaf colonization per degree-day. There also was a linear relationship between the logarithm of degree-days and the logarithm of percent leaf area showing visible symptoms in a susceptible cultivar. The degree-day intercept of this relationship represented the incubation period (about 500 degree-days). The degree-days required to detect bioluminescence was not considerably different between susceptible and resistant cultivars. However, the subsequent rates of leaf colonization were significantly lower for a resistant cultivar than for a susceptible cultivar in all temperature regimes. The results suggest that multiplication of the pathogen in the leaf tissues is optimized in the susceptible cultivar. In contrast, in the resistant cultivar, the defense mechanisms overshadow the temperature effect. The differential response to temperatures may be an additional indicator of cultivar susceptibility.

Asymptomatic cerebrovascular lesions detected by magnetic resonance imaging in patients with systemic lupus erythematosus lacking a history of neuropsychiatric events

OBJECTIVE

To clarify the extent of asymptomatic cerebrovascular involvement in systemic lupus erythematosus (SLE).

PATIENTS AND METHODS

Cerebral magnetic resonance imaging (MRI) findings and ultrasonography findings of 100 patients with SLE lacking present or past clinical neurologic deficits were compared with 66 age-matched volunteers to determine the combined intima-media thickness (IMT) of the common carotid artery, and tests for anti-cardiolipin antibodies (aCL).

RESULTS

Thirty-eight patients, but only 2 controls, showed imaging abnormalities. Among 23 SLE patients with cerebrovascular lesions by MRI who underwent single-photon emission computed tomography (SPECT), 14 showed hypoperfusion of the lesion. The IMT value and prevalence of aCL did not differ between the 55 SLE patients tested and controls. SLE disease activity index (SLEDAI) as assessed by a quantitative clinical index was significantly greater in patients with brain lesions than in those without.

CONCLUSION

The prevalence of asymptomatic brain lesions in SLE patients is highs and shows a relationship to disease activity.

The kinase inhibitor fasudil (HA-1077) reduces intimal hyperplasia through inhibiting migration and enhancing cell loss of vascular smooth muscle cells

Smooth muscle cell (SMC) migration plays an important role in restenosis after angioplasty. Myosin phosphorylation is necessary for cell migration. Fasudil is an inhibitor of protein kinases, including myosin light chain kinase and Rho associated kinase, thereby inhibiting myosin phosphorylation, and it has been clinically used to prevent vasospasm following subarachnoid hemorrage. Based on these findings, we examined the anti-migrative action of fasudil. In SMC (SM-3), fasudil (1-100 microM) inhibited SMC migration in a dose-dependent manner (p < 0.001). Fasudil suppressed actin stress fiber formation dose dependently. In rabbit carotid artery, fasudil (10 mg/kg/day) markedly reduced intimal hyperplasia 14 days following balloon injury. Cell kinetic study showed that fasudil did not affect proliferation but enhanced cell loss in the media after injury. We concluded that fasudil reduced neointimal formation after balloon injury through both inhibiting migration and enhancing cell loss of medial SMC.

Comparisons of single versus multiple bacterial species on biological control of anthurium blight

ABSTRACT Effects of single versus multiple biological control agents (BCAs) on suppression of bacterial blight of anthurium were studied using a bioluminescent strain (V108LRUH1) of Xanthomonas campestris pv. dieffenbachiae. When five BCAs (GUT3, GUT4, GUT5, GUT6, and GUT9) were coinoculated in various combinations with V108LRUH1 into filter-sterilized guttation fluids of anthurium plants, a mixture of all five strains or four strains without GUT9 was most inhibitory to V108LRUH1. None of the individual BCAs inhibited V108LRUH1 in the guttation fluid. When BCAs were sprayed at congruent with10(8) CFU/ml on the foliage of a susceptible cultivar 1 day prior to inoculation with V108LRUH1, GUT6 alone and any mixtures containing GUT6 were highly effective in suppressing wound invasion and subsequent leaf infection by V108LRUH1. When tested on several cultivars that differed in susceptibility to the disease, the mixture of five strains or four strains without GUT9 consistently suppressed leaf infection regardless of the cultivars. In some cultivars, BCAs completely suppressed both wound and hydathode invasion by V108LRUH1, resulting in no infection in many leaves. These results indicate that application of bacterial mixtures provides anthurium cultivars with bacterial communities suppressive to X. campestris pv. dieffenbachiae. The results also suggest that selecting an effective mixture of BCAs first and then removing ineffective strains may be a better general approach to finding the most effective BCAs than finding individual strains and combining them.

Transvaginal Doppler assessment of fetal intracranial venous flow

OBJECTIVE

To investigate physiologic blood-flow-velocity waveform patterns of the fetal cerebral venous system during normal pregnancies by transvaginal Doppler studies and to evaluate cases with abnormal venous-flow patterns.

METHODS

Internal cerebral veins and the three dural sinuses, those of the superior sagittal sinus, vein of Galen, and straight sinus, were examined in normal cephalic-presenting fetuses of 20-40 weeks' gestation. For analysis, the venous index was defined as maximum minus minimum velocity divided by maximum velocity. Different cases with intracranial abnormalities were evaluated with emphasis on abnormal venous blood-flow patterns.

RESULTS

Internal cerebral veins had pulsatile patterns with a venous index of 0.22 in 47.6% of fetuses, whereas all fetuses had pulsations in the dural sinuses. The vein of Galen had a significantly lower venous index (0.31) than the superior sagittal sinus (0.39) and the straight sinus (0.36), indicating that the amplitude of the intracranial venous pulsation might increase as the flow runs from the periphery toward the proximal portion. Significant regression lines of venous index were obtained, indicating the stability of the pulsation during pregnancy. A flat pattern of superior sagittal sinus flow was found in three cases of hydrocephalus and one of craniosynostosis.

CONCLUSION

We showed the normal patterns of fetal cerebral venous blood-flow velocity and the abnormal patterns which might be associated with increased intracranial pressure. Doppler assessment of the intracranial venous system enabled us to evaluate intracranial abnormalities accompanied by increased intracranial pressure that might have prognostic clinical importance.

Relationship between brain atrophy estimated by a longitudinal computed tomography study and blood pressure control in patients with essential hypertension

To evaluate the relationship between blood pressure control and the progression of brain atrophy in the elderly, patients with essential hypertension and brain atrophy were longitudinally evaluated using computerized tomography (CT). The study evaluated 48 patients with essential hypertension aged 46-78 years, and 30 sex- and age-matched normotensive control subjects. The extent of brain atrophy as determined by caudate head index (CHI), the inverse cella media index (iCMI), and Evans' ratio (ER) was estimated twice at an interval of 5-9 years (mean, 6.9 years). The mean annual increases in CHI (deltaCHI), iCMI (delta iCMI), and ER (deltaER) were evaluated. Mean blood volume in the common carotid artery (BF) and the decrease in BF per year (deltaBF) were also determined. The deltaCHI, delta iCMI, and deltaER increased with age in the hypertensive subjects as well as the control group across all age groups evaluated. The deltaCHI, delta iCMI, and deltaER were significantly greater in the patients with essential hypertension in their 50 s as compared with the controls. In patients with essential hypertension aged 65 years or older, the deltaCHI, delta iCMI, and deltaER were significantly lower in the group in whom the blood pressure was controlled within the range of borderline hypertension than the groups in which it was controlled in the range of normal or mild hypertension. In the younger patients under the age of 65 with essential hypertension, blood pressure control did not affect the deltaCHI, delta iCMI, and deltaER. The deltaCHI, delta iCMI, and deltaER were significantly correlated with deltaBF in both groups. These findings indicate that control of systolic blood pressure within the range of borderline hypertension may delay the progression of brain atrophy in elderly patients with essential hypertension.

[Carotid artery atherosclerosis in patients with myocardial infarction]

This study investigated carotid artery atherosclerosis in patients with myocardial infarction. One hundred and two patients with acute myocardial infarction [Group MI: male 86, female 16, mean 62 (range 43-79) years] and 55 normal subjects matched for age and sex with negative responses to exercise electrocardiogram testing (control group: Group C) were included. Patients in Group MI were divided into 3 subgroups according to coronary angiographic findings as follows: 57 patients with one-vessel disease (Group I: mean 59 years), 34 with 2-vessel disease (Group II: mean 64 years), and 11 with 3-vessel disease (Group III: mean 64 years). Intima-media complex thickness (IMT) of the bilateral common carotid arteries (15 mm proximal to the bifurcation) and the internal carotid arteries (15 mm distal to the bifurcation) were measured by high-resolution B-mode ultrasonography, and the sum of maximum IMT of the bilateral carotid arteries (sigma IMT) were calculated. sigma IMT was significantly greater in Group MI (2.5 +/- 0.5 mm) than in Group C (1.8 +/- 0.3 mm), sigma IMT was 2.5 +/- 0.5 in Group I, 2.6 +/- 0.5 in Group II, and 2.7 +/- 0.4 mm in Group III. There was a significant positive correlation between sigma IMT and the number of involved vessels (tau = 0.45, p < 0.01). The percentage of patients with carotid artery atherosclerosis was 2% in Group C, 63% in Group MI, 54% in Group I, 68% in Group II, and 82% in Group III (p < 0.001). This study suggests that carotid artery atherosclerosis in patients with myocardial infarction is frequently complicated and severe, and more frequently complicated in patients with severe coronary artery disease.

Differential Susceptibility of Anthurium Cultivars to Bacterial Blight in Foliar and Systemic Infection Phases

Susceptibility of anthurium cultivars to systemic infection by the bacterial blight pathogen, Xanthomonas campestris pv. dieffenbachiae, was examined using a bioengineered bioluminescent strain (V108LRUH1) and compared with susceptibility to foliar infection. Eight cultivars with different levels of susceptibility to foliar infection were evaluated for their susceptibility to systemic infection. Petioles of second youngest leaves cut near the main stem were inoculated with strain V108LRUH1, and subsequent movement of this bacterium into other petioles was monitored by observing bioluminescence from the plants. The actual extent of systemic movement was determined by reisolating V108LRUH1 from dissected segments of the remaining petioles. In susceptible cultivars, the pathogen advanced very rapidly and nearly reached the distal end of petioles. In resistant cultivars, the pathogen was detected in none (or very few) of the petiole segments. However, the susceptibility ranking among the tested cultivars for systemic infection did not always correspond to the ranking determined for foliar infection: i.e., one cultivar that was susceptible to foliar infection was highly resistant to systemic infection, and vice versa. This suggests that cultivar susceptibility of anthuriums to bacterial blight may differ depending on the phase of disease progression, and thus evaluation for both disease phases is essential for complete understanding of cultivar susceptibility.

Transvaginal sonography of the fetal brain: detection of abnormal morphology and circulation

AIM

To analyze the incidence, transvaginal detection age, sonographic appearance, clinical course, and outcomes of pregnancy in cases with abnormal fetal brain structure and/or circulation, and to evaluate the clinical significance of sonographic abnormalities.

METHODS

Serial observation of the fetal brain and intracranial Doppler assessment by transvaginal approach at four-week intervals were performed in 306 singleton fetuses from the first trimester and 13 referral cases at our ultrasound units from January 1996 to December 1997. Detection of abnormalities was followed by subsequent serial scans every one or two weeks.

RESULTS

Morphological abnormalities were found in 66 cases: open neural tube defect (9 cases), disorders of prosencephalic development (2), ventriculomegaly with cerebellar hypoplasia (1), hydrocephalus (1), craniosynostosis (1), unclassified brain anomaly (1), brain atrophy (1), isolated choroid plexus cysts (19), choroid plexus cysts with cerebellar hypoplasia (2), lateral ventricular asymmetry (26), and subependymal cyst (3). Chromosomal aberration was found in 4 cases. Artificial abortion was performed in 10 cases and fetal demise occurred in 2 cases. Isolated choroid plexus cysts, isolated ventricular asymmetry and subependymal cyst were not clinically significant. Two abnormal flow patterns of superior sagittal sinus, sharp doubled pulsatile pattern, and disappearance of normal pulsatile pattern were found in different situations.

CONCLUSION

Serial transvaginal observation of the fetal brain provided evidence of hitherto unreported intracranial abnormalities: subependymal cyst, craniosynostosis, medullary kink in Chiari malformation, brain damage, and abnormal venous flows. Venous flow assessment may be of great potential in predicting fetal neurological well-being.

Effects of sex, height and age on motor evoked potentials with magnetic stimulation

Magnetic stimulation of the brain and cervical and lumbar spinal roots was performed on 48 healthy subjects in order to investigate the effects of sex, height and age on motor evoked potentials (MEPs). The compound muscle action potentials were recorded from the abductor pollicis brevis and abductor hallucis muscles. The central motor conduction time (CMCT) was measured between the cerebral cortex and the cervical root and also between the cerebral cortex and the lumbar root. A multiple regression analysis was used to determine which of the physical variables, namely sex, height and age, were significant. A significant gender difference was observed in the MEP latencies and CMCT of the leg, but not in those of the hand. Both height and age had a significant effect on the leg MEP latencies with a lesser effect on the hand MEP latencies. The leg CMCT was also significantly influenced by height and age, while the hand CMCT was not. These results thus suggest that physical variables are very important in defining normal MEPs, especially in the lower limbs. Therefore, when we assess motor function in patients with neurological disorders, both the patients and control groups should be matched for sex, height and age distribution.

Inhibition of migration and proliferation of vascular smooth muscle cells by dehydroepiandrosterone sulfate

Dehydroepiandrosterone (DHEA) and its sulfate (DHEA-S) are the most abundant steroids in humans, and their serum concentrations progressively decrease with age. Although relationships between DHEA(-S) and many age-related illnesses have been postulated, the mechanisms for their effects remain unknown, and specific receptors for these molecules have not been identified. In this paper, to investigate the role of DHEA(-S) in atherogenesis, we studied the proliferation and migration of a rabbit vascular smooth muscle cell line, SM-3, in the presence of DHEA(-S). Cellular proliferation was inhibited by DHEA-S, and to a lesser extent by DHEA. Modified Boyden's chamber assays revealed that DHEA-S inhibited the migration of SM-3 cells toward PDGF-BB. In cell attachment assays, DHEA-S inhibited the attachment of SM3 cells to fibronectin. It was suggested that the inhibitory effect of DHEA-S for SM-3 proliferation and migration was due to the decreased interaction with fibronectin. Scatchard analysis revealed the presence of two populations of DHEA-S binding sites in the nuclear fraction, and a smaller number in the cytosolic fraction. Since the dissociation constant of the higher affinity site was similar to the serum DHEA-S concentration in humans (Kd = 5.8 microM), this binding site could be functional under physiologic conditions. These findings suggest that there may be receptor-mediated anti-atherogenic actions of DHEA-S.

[Hemodynamics of asymptomatic brain infarction determined by Doppler sonography]

We compared the usefulness of two methods for diagnosing asymptomatic brain infarction: an ultrasonic quantitative flow measurement system (QFM) and a transcranial Doppler arteriography (TCDA). A total of 137 patients (73 men and 64 women) who underwent magnetic resonance imaging of the brain, QFM, and TCDA were enrolled. Their ages ranged from 41 to 83 years (mean age, 63 years). The patients were divided into 3 groups: 45 without cerebrovascular disease (Group N); 40 with asymptomatic brain infarction (Group AS); and 52 with lacunar infarction (Group LI). The mean blood flow in the common carotid artery (CCA-BF) was measured by QFM. The mean blood velocity and Fourier pulsatility index in the middle cerebral artery (MCA-BV, MCA-PI) were measured by TCDA. In Group N, 28 patients were examined twice at a mean interval of 2 years; 19 remained without asymptomatic brain infarction (Group N1), and asymptomatic brain infarction developed in the remaining 9 (Group N2). The 3 groups differed significantly in MCA-PI (N < AS < LI), but not in CCA-BF or in MCA-BV. The MCA-PI in Group N2 was higher than that in Group N1. These results indicate that the Fourier pulsatility index determined by TCDA may be useful for detecting the onset of asymptomatic brain infarction.

[Relationship between carotid atherosclerosis and plasma endothelin-1 concentration in senile patients with hypertension]

The relationship between carotid atherosclerosis and plasma endothelin-1 (ET-1) concentration was studied in senile patients with essential hypertension. A total of 212 patients (83 M, 129 F; mean age, 63 years) with essential hypertension (WHO stage I-II), and 109 age-matched control subjects (mean age, 61 years) were enrolled in the study. The maximum thicknesses of the intima-media complex (IMTmax) in the right common carotid artery (CCA) and the right internal carotid artery (ICA) was measured by B-mode ultrasonography, and ET-1 was measured by enzyme immunoassay. ET-1 levels were significantly higher in the hypertensive patients than in the control subjects. In middle-aged patients (35-64 years old), IMTmax values of the ICA in patients with high ET-1 concentrations (ET-1 > or = 1.71 pg/ml) were significantly higher than in patients with normal ET-1 concentrations (ET-1 < 1.71 pg/ml). However, the IMTmax of the CCA did not show a similar correlation. In senile patients (65-83 years old), both the CCA and ICA IMTmax values were significantly higher in patients with high ET-1 concentrations than in those with normal ET-1 concentrations. These results indicate that high ET-1 levels in middle-aged patients with essential hypertension may play a role in the progression of ICA atherosclerosis. High ET-1 levels in senile patients with essential hypertension may cause progression of atherosclerosis in both the ICA and CCA.

[The relationship between brain atrophy and asymptomatic cerebral lesions]

In order to clarify the relationship between brain atrophy and asymptomatic cerebral lesions, total of 235 subjects (130 males and 105 females), who had neither neurologic deficits nor organic lesions on cerebral computed tomography, were studied. The subjects' ages ranged from 40 to 86 years (mean 66). They were divided into two groups: 90 controls without hypertension or diabetes mallitus (Group C), and 145 patients with essential hypertension (Group H). Brain atrophy was diagnosed using the caudate head index (CHI). Asymptomatic cerebral lesions on magnetic resonance imaging were defined as asymptomatic lacunae and white matter lesions. Caudate head index was higher in Group H than it was in Group C, and CHI in both groups was significantly correlated with the number of asymptomatic lacunae and the severity of white matter lesions on magnetic resonance imaging. These results indicate that brain atrophy may progress along with asymptomatic cerebral lesions.

[Effects of long-term antihypertensive medication on common carotid hemodynamics in elderly patients with essential hypertension]

This longitudinal study was performed in order to clarify the effects of long-term antihypertensive medication on common carotid hemodynamics. A total of 84 patients (54 males and 30 females), who had been receiving treatment with antihypertensive medications for 5 years, were enrolled in this study. The subjects' ages ranged from 62 to 74 (mean 67). They were divided into three groups: 40 were treated with diuretics only (Group D), 28 with calcium antagonists only (Group C), and 16 with angiotensin converting enzyme inhibitors only (Group A). Mean blood flow volume (BF) and circulation resistance (Z) at the common carotid artery were measured by an ultrasonic quantitative flow measurement system. Blood flow volume, Z, and mean blood pressure (MBP) were measured twice over a 5-year period in patients and in 49 age-matched normal controls (Group N). Annual reductions in BF (delta BF) and MBP (delta MBP), and annual increases in Z (delta Z) were calculated. Blood flow volume of Group D showed larger decreases than that of the other three groups. Circulation resistance of Group C showed smaller increases than that of Group N. Reductions of BF and Z of Group A were similar to those of Group N. Reductions of Z of Group C showed a significant correlation with delta MBP. These results indicate that calcium antagonists may have beneficial effects on common carotid hemodynamics in elderly patients with essential hypertension.

Inhibition of smooth muscle cell migration by the p21 cyclin-dependent kinase inhibitor (Cip1)

In vascular smooth muscle cells (SMCs), proliferation and migration contribute to lesion formation after arterial injury. In the cell cycle, several cyclin-dependent kinases (cdks) inhibitors are implicated in the regulating of cyclin-cdk activity such as p21Cip1, p16Ink4 and p27Kip1. Although Cip1 inhibits SMC proliferation, its effects on SMC migration are unknown. To test the hypothesis that Cip1 inhibits SMCs migration and proliferation, we transfected the Cip1 gene into a strain of rabbit aortic SMCs (SM3 cells). Both the spreading and the attachment of Cip1-transfected SM3 cells to extracellular matrices (ECMs) were inhibited compared to that of vector-transfected cells. In the modified Boyden's chamber assay the effect of fibronectin on the migratory activity of Cip1-transfected SM3 cells was significantly less than that of vector transfected cells in response to PDGF-BB. These data suggested that Cip1 inhibited both the migration and proliferation of SMC.