Early Assessment of Radiation Treatment at Clinical Field Strength by D2O Administration and Deuterium MRI

PURPOSE/OBJECTIVE(S)

An accurate and non-invasive assessment of tumor response following treatment is essential. Traditional anatomical imaging techniques are insufficient before a significant morphological change can be observed. Metabolic imaging of molecular processes in the living body is also used. In recent years, deuterium magnetic resonance spectroscopic (MRS) imaging has been demonstrated as an alternative for cancer metabolic imaging by high-field (4-11T) MRI using deuterium-labeled molecules as a contrast agent. The study aim was to evaluate the feasibility of using deuterium MRI 1.5T for tumor visualization and early assessment of the efficacy of three anticancer treatment strategies (radiation and anticancer drugs) in pancreatic cancer model mice given heavy water (D2O) to induce deuterium (2H)-tissue labeling.

MATERIALS/METHODS

A MIA PaCa-2 pancreatic cancer model of six BALB/c-nu mice was prepared, and repeated deuterium MRI was performed during the first 10 days after starting free drinking of 30% D2O. We also evaluated 2H accumulation in the tumor after irradiation, bevacizumab administration, or gemcitabine administration of other 20 mice. Additional confirmatory proton MRI, ex vivo metabolic hyperpolarization 13C-MRS and histopathology were performed.

RESULTS

The mouse's whole-body distribution of 2H was visible 1 day after drinking, and the signal intensity increased daily. Although the tumor size did not change 1 and 3 days after irradiation, the amount of 2H in the tumor decreased significantly. The 2H image intensity of the tumor also significantly decreased after the administration of bevacizumab or gemcitabine. Metabolic hyperpolarization 13C-MRS, proton MRI and 2H-NMR spectroscopy confirmed the efficacy of the anticancer treatments.

CONCLUSION

Deuterium MRI at 1.5T proved feasibility to track 2H distribution throughout mouse tissues during D2O administration and revealed a higher 2H accumulation in the tumor xenografts. This research demonstrated a promising successful method for early assessment of radiotherapy and chemotherapy of pancreatic cancer.

The New Quantum Image by Dynamic Nuclear Polarized MRI for the Assessment of Cardiac Radioablation to the Cavotricuspid Isthmus

PURPOSE/OBJECTIVE(S)

Cardiac arrhythmias are usually treated with invasive, time consuming catheter ablation techniques. While recently stereotactic body radiotherapy (SBRT) is an emerging non-invasive treatment in the management of cardiac arrhythmias. To identify and assess the cardiac radioablation by MR examination, including diffusion-weighted MRI, dynamic Gd-enhanced MRI, MR spectroscopy, and T2-weighted MRI early after SBRT is very difficult. We have been developing the free radical imaging methods using Dynamic Nuclear Polarization (DNP)-MRI with nitroxyl radicals as a redox probe (e.g., 4-Methacryloyloxy-2,2,6,6-tetramethylpiperidine-1-oxyl (Tempo methacrylate; TempoMC)). In this study, we examined the possibility of in vivo spatiotemporal visualization of SBRT for cardiac radioablation to the cavotricuspid isthmus (CTI) based on redox reaction by in vivo DNP-MRI.

MATERIALS/METHODS

All animal procedures were approved by institutional animal care and use committee and performed in full compliance with its guidelines. This study was conducted with two approaches. First, four mini pigs underwent electrophysiology assessment using electroanatomic mapping (EAM) before and 3 months after SBRT with single-fraction doses of 25 Gy. The target of CTI was defined by cardiologist. We defined the planning target volume (PTV): the internal margin (IM) + set up margin (SM) = SI 15 mm, AP 10mm, LR 10 mm were added to the target. Radiotherapy plans were created by the software used in daily clinical practice. Second, free radical imaging by low filed type of DNP-MRI was performed on the four mice before and after 25 Gy and 10 Gy irradiation to whole heart. ESR signal measurements were also performed.

RESULTS

A total dose of 25 Gy was successfully delivered to PTV in a single procedure in all mini pigs. EAM visualized the irradiated site and confirmed clockwise conduction block across the CTI. Although routine MRI could not detect the cardiac radiation injury clearly, the four mice of heart were well delineated on MRI and clearly visualized by DNP-MRI. DNP-MRI signal of TempoMC were decreased depending on prescribed irradiation dose.

CONCLUSION

These data demonstrated the safety and feasibility of SBRT for creating conduction block across the CTI in mini pigs. Although to identify and assess the irradiated site by routine MR examination was impossible, the free radical imaging methods using Dynamic Nuclear Polarization (DNP)-MRI with TempoMC could be a promising successful method for the assessment of cardiac radioablation. This new quantum image by DNP-MRI will open the possibility of treating cardiac arrhythmias by SBRT safety and noninvasively.

Gastrointestinal stromal tumour lacking mutations in the KIT and PDGFRA genes in a cat

Molecular subtyping in gastrointestinal stromal tumours is a useful method for predicting the efficacy of treatment using tyrosine kinase inhibitors in humans. However, owing to the paucity of reports on mutational analyses, the association between genetic mutations and the therapeutic response to tyrosine kinase inhibitors remains unclear in feline gastrointestinal stromal tumours. In this report, we describe the case of a cat with a gastrointestinal stromal tumour which was unresponsive to tyrosine kinase inhibitors. A mutational analysis revealed that the cat lacked mutations in both the KIT and platelet-derived growth factor receptor-alpha (PDGFRA) genes. Our findings are consistent with the fact that KIT/PDGFRA wild-type gastrointestinal stromal tumours are less responsive to tyrosine kinase inhibitors in humans. This signifies the need for further evaluation and possibly individualised treatment for gastrointestinal stromal tumours in cats on the basis of mutational analyses.

Three-dimensional conformal radiation therapy for canine aortic body tumour: 6 cases (2014-2019)

OBJECTIVE

To determine the feasibility of three-dimensional conformal radiation therapy for canine aortic body tumours.

MATERIALS AND METHODS

Medical records of dogs that had undergone three-dimensional conformal radiation therapy with presumptive diagnosis of aortic body tumour were reviewed for clinical characteristics, treatment modality and outcomes.

RESULTS

Eight dogs were diagnosed with aortic body tumour and were treated with three-dimensional conformal radiation therapy. One dog had proliferation of a mass in the right atrium during treatment and died of respiratory distress. Another dog did not undergo follow-up CT to evaluate the treatment response due to the increased blood urea nitrogen values. The remaining 6 dogs were included in the case series. Radiotherapy was performed using a median dose per fraction of 7 Gy (3.3-7.14 Gy), a median of seven divided doses (7-15) and a total median dose of 49 Gy (45-50 Gy). The median number of CT scans during the follow-up period was 5 (range: 3-8 times). CT revealed acute side effects in four dogs-grade 1 effects related to the lung (n = 4) and skin (n = 2). Self-limiting or asymptomatic late side effects (grade 1 lung-related effect) were observed in three dogs. After therapy, one dog demonstrated a complete response, another demonstrated a partial response and the disease remained stable in four animals. The median follow-up period was 514.5 (235-1219) days. After three-dimensional conformal radiation therapy, the aortic body tumour reduced gradually over time without regrowth in all these 6 dogs.

CLINICAL SIGNIFICANCE

In this small case series, aortic body tumours responded to three-dimensional conformal radiation therapy. Transient and self-limiting side effects of the treatments were common. Further controlled studies are required to prove the effectiveness and the safety of this intervention.

Combination therapy with cisplatin, 5'-deoxy-5-fluorouridine (5'-DFUR) and mitomycin (MMC) in patients with inoperable, advanced gastric cancer

The optimal dose of cisplatin (CDDP) for combination chemotherapy for the treatment of inoperable, advanced gastric cancer has yet to be established. We therefore performed a randomized study to compare the therapeutic usefulness of two dose levels of cisplatin. 5'-deoxy-5-fluorouridine (5'-DFUR 1,400 mg/m(2)/d) was given orally on days 1 to 4 and 15 to 18. Mitomycin C (MMC, 5.75 mg/m(2)/d) was injected intravenously on day 5. In addition, 80 mg/m2/d of CDDP (regimen A) or 60 mg/m(2)/d of CDDP (regimen B) was given by 2-h intravenous drip infusion on day 5. This treatment cycle was repeated every four weeks. Fifty-six patients were enrolled. Clinical response was evaluated in 32 patients (regimen A, 16 patients; regimen B? 16 patients) with measurable lesions. The response rate was significantly higher with regimen A (9 PR/16, 56.3%) than with regimen B (3 PR/16, 18.9%) (p=0.028, chi(2) test). Median survival was slightly but not significantly longer with regimen A (7.4 months) than with regimen B (6.3 months). Drug toxicity included myelosuppression and gastrointestinal symptoms, but there were no serious adverse reactions or differences in safety between the treatment regimens. Regimen A was associated with a high response rate and low toxicity. The optimal dose of CDDP in combination with 5'-DFUR and MMC for the treatment of advanced gastric cancer is regarded to be 80 mg/m(2).

Search for the Θ+ pentaquark via the π(-)p→K(-)X reaction at 1.92 GeV/c

The Θ(+) pentaquark baryon was searched for via the π(-)p→K(-)X reaction with a missing mass resolution of 1.4 MeV/c(2) (FWHM) at the Japan Proton Accelerator Research Complex (J-PARC). π(-) meson beams were incident on the liquid hydrogen target with a beam momentum of 1.92 GeV/c. No peak structure corresponding to the Θ(+) mass was observed. The upper limit of the production cross section averaged over the scattering angle of 2° to 15° in the laboratory frame is obtained to be 0.26 μb/sr in the mass region of 1.51-1.55 GeV/c(2). The upper limit of the Θ(+) decay width is obtained to be 0.72 and 3.1 MeV for J(Θ)(P)=1/2(+) and J(Θ)(P)=1/2(-), respectively, using the effective Lagrangian approach.

Networking possibilities for waste recycling in Miyagi prefecture, Japan

Successful case studies for waste recycling in Japan have not been evaluated. The evaluation of economic efficiency and environmental effects were lacking at the time the actual network was established. A waste/resource input/output (I/O) coincidence retrieval system called ZENESYS was developed to examine the usefulness of a waste-exchange network in a nonmanufacturing district. We analyzed data from the Miyagi prefecture, a region without heavy industry. The data were collected from 77 companies using a questionnaire and interviews. A total of 33 possible waste exchange links arose after analysis using ZENESYS. However, these were frail networks that relied heavily on the construction industry. Two waste recycling technologies were selected from the ZENESYS database: reclaiming fuel from waste plastic and making construction materials from bottom ash. Evaluation of the environmental effects and economics of these two technologies showed they were both suitable for the environment, but no profit was made from reclaiming fuel from waste plastics. We concluded that in an area with no heavy industry, it may be difficult to adopt recycling technologies that have high environmental and economic performance. Materials are difficult to circulate among manufacturing industries even if a waste-exchange network exists, and resources are consumed during transportation and recycling.

Phase 1/11 study of bi-weekly irinotecan plus cisplatin in the treatment of advanced gastric cancer

OBJECTIVES

To conduct a phase I/II study of irinotecan with cisplatin to establish a recommended dose, and assess the safety, efficacy and feasibility of this regimen in unresectable advanced or recurrent gastric cancer.

PATIENTS AND METHODS

In the phase I portion of the study, patients received a fixed dose of cisplatin (30 mg/m2) with escalating doses of irinotecan, ranging from 30 mg/m2 to 70 mg/m2, on days 1 and 15. In the phase II portion of the study, 40 patients were evaluated for response and safety at the recommended dose.

RESULTS

Eighteen patients were enrolled in the phase I study. Dose-limiting toxicity (diarrhea and neutropenia) appeared at the irinotecan dose of 70 mg/m2. Therefore, the recommended irinotecan dose was 60 mg/m2. In the phase II study, 40 patients received cisplatin (30 mg/m2) plus irinotecan (60 mg/m2). Twenty-five out of 40 patients had received prior chemotherapy. The median number of cycles was 3.5. The response rate was 32.5% (13/40) overall, and 53.3% (8/15) in patients without prior chemotherapy. The median time to tumor progression (TTP) was 162 days. The median survival time was 288 days. Four patients (10%) developed grade 4 neutropenia and 3 patients (7.5%) developed grade 4 anemia. The only observed non-hematological toxicity at grade 3 or higher was diarrhea, seen in 2.5% (1/40) of the patients.

CONCLUSION

Bi-weekly administration of irinotecan and cisplatin is safe and active for the management of unresectable advanced or recurrent gastric cancer.

Human amniotic epithelial cells are morphologically homogeneous: enzymehistochemical, tracer, and freeze-substitution fixation study

We examined the fine subcellular morphology of human amniotic epithelial cells and attempted to answer the question as to whether amniotic epithelial cells consist of heterogeneous or homogeneous cells, which has long been controversial. Study subjects were fetal membranes from pregnant women (n=18) who abdominally gave birth to healthy infants at term (37.9+/-0.7 weeks of gestation, mean+/-sd). The methods employed were transmission electron microscopy, enzymehistochemistry, tracer permeability analysis, and freeze-substitution fixation. The labelings for acid phosphatase, cytochrome c oxidase, and CA++ATPase were seen in the lysosomes, mitochondria, and lateral plasma membranes, respectively. The staining distribution pattern of these three enzymes and the morphology of the organelle highlighted by these enzymehistochemistry did not differ among cells. Freeze-substitution fixation revealed that intercellular spaces in the amniotic epithelial cells were narrower than previously thought, but the tracers (horse radish peroxidase and lanthanum nitrate) fully entered these spaces. There were no variations in the tracer permeability among cells. All cells from freeze-substitution fixation exhibited the same morphological features. From these morphological viewpoints, we conclude that human term amniotic epithelial cells consist of a homogeneous cell population.

Chorion laeve trophoblasts of preeclamptic fetal membranes: histochemically detectable enzyme activities do not change at a subcellular level

We examined the subcellular localization of ADP-degrading activity and cytochrome c oxidase (CCO) activity in chorion laeve trophoblasts from term and near term human fetal membranes, and compared them with those from severe preeclamptic fetal membranes. The methods used for the detection of enzyme activities were the lead nitrate method for ADP-degrading activity and the diaminobenzidine method for CCO. Precipitates indicative of ADP-degrading activity were visible on surface microvillous plasma membranes of chorion laeve trophoblasts both from normal and preeclamptic fetal membranes. The intensity and distribution patterns were the same in the normal and preeclamptic subjects. CCO labeling was visible in almost all laeve trophoblastic mitochondria both in normal and preeclamptic cases. Previously, we demonstrated that in preeclamptic villous trophoblasts there were decreases in ADP-degrading activity and the presence of CCO-negative mitochondria, which were proposed to lead to dysfunction of each villous trophoblast, and finally to placental insufficiency in preeclampsia. Reductions or changes in enzyme intensities/distribution patterns, which are characteristic features of preeclamptic villous trophoblasts, were absent in chorion laeve trophoblasts in preeclampsia. These results suggest that in preeclampsia there are no, or at least less severe, abnormalities in the enzyme activities of chorion laeve trophoblasts, compared with villous trophoblasts, as far as enzyme-histochemically detectable enzymes are concerned.

Enzyme-cytochemically detectable glucose-6-phosphate dehydrogenase in human villous macrophages (Hofbauer cells)

Though various tissue macrophages possess high glucose-6-phosphate dehydrogenase (G6PD) activity, which plays an important role in their phagocytosis/bactericidal function, the presence of this enzyme in human placental villous macrophages (Hofbauer cells) has not been determined. We examined the ultrastructural localization of glucose-6-phosphate dehydrogenase (G6PD) in Hofbauer cells in first and second trimester placental villi, using a newly developed enzyme-cytochemistry (copper-ferrocyanide) method. Electron-dense deposits indicative of G6PD activity were clearly visible in the cytoplasm and on the cytosolic side of the endoplasmic reticulum of Hofbauer cells. Positive and negative cytochemical controls ensured specific detection of enzyme activity. These observations indicated that Hofbauer cells abundantly possessed enzyme-cytochemically detectable G6PD activity. Hofbauer cell G6PD may play a role in placental defense, by supplying NADPH-dependent enzymes (i.e. nitric oxide synthase or NADPH oxidase) with NADPH. This enzyme may also fuel Hofbauer cells with ribose 5-phosphate during their cell proliferation and cell division.

Creatine kinase gene mutation in a patient with muscle creatine kinase deficiency

BACKGROUND

We describe a 56-year-old woman admitted to the hospital with a diagnosis of acute myocardial infarction without an increase of serum creatine kinase (CK) activity during her clinical course. She died on the 11th hospital day, and the diagnosis was confirmed by autopsy. The patient had had no previous muscular symptoms.

METHODS

Expression of the CK-muscle (CK-M) protein in cardiac tissue was examined by immunoblotting and immunochemical staining. CK-M mRNA expression was estimated by semiquantitative reverse transcription-PCR. Gene structure of CK-M was determined by Southern blotting and direct sequencing of 2251 bp. Existence of a point mutation in the CK-M gene was examined by restriction fragment length polymorphism analysis of PCR products (PCR-RFLP) in the patient and in 108 controls.

RESULTS

CK-M protein in the myocardial tissue of the patient was substantially lower (103 +/- 7 ng/mg protein) than in control myocardial tissue (35 800 +/- 2860 ng/mg protein). Immunoreactive CK-M in the patient tissue sample was 0.3% of the value for the control sample. CK-M mRNA was 53-fold less in the patient sample compared with the control. This very low expression of CK-M mRNA was considered to be the primary reason for CK-M deficiency. Direct sequencing revealed a point mutation at residue 54 in exon 2, which was specific for the patient. No other abnormalities were found in the CK-M gene of the patient.

CONCLUSIONS

This report identifies a molecular abnormality in human CK deficiency and discusses the physiologic relevance of CK-M.

Cytochemically detectable glucose-6-phosphate dehydrogenase is present in human fetal membrane chorion laeve trophoblasts

We examined the ultrastructural localization of glucose-6-phosphate dehydrogenase (G6PD), a NADPH-generating enzyme, in human fetal membranes at various gestational ages, using newly developed enzyme histochemistry (copper-ferrocyanide method). Electron-dense deposits indicative of G6PD activity were clearly visible in the cytoplasm and on the cytosolic side of the endoplasmic reticulum of chorion laeve cytotrophoblasts at various gestational ages. Positive and negative cytochemical controls ensured specific detection of enzyme activity. These observations indicated that chorion laeve trophoblasts were the site of NADPH production. Chorion laeve trophoblast G6PD may play a significant role in fetal membrane physiology, by delivering NADPH to NADPH-dependent oxidoreductases which these cells possess.

Morphology of the mitochondria and endoplasmic reticula of chorion laeve cytotrophoblasts: their resemblance to villous syncytiotrophoblasts rather than villous cytotrophoblasts

We examined the morphological features of the mitochondria and endoplasmic reticula of chorion laeve cytotrophoblasts from term human fetal membranes, and compared them with those of syncytiotrophoblasts and cytotrophoblasts from human placental villi. Ultrastructural enzyme histochemistry of cytochrome c oxidase and glucose-6-phosphatase were used as cytochemical markers for these intracellular organelles. Chorion laeve cytotrophoblasts possessed abundant endoplasmic reticula, and small mitochondria with a few cristae, which were characteristic of villous syncytiotrophoblasts rather than villous cytotrophoblasts. As for these organellar structures, statistical analysis confirmed similarities between chorion laeve cytotrophoblasts and villous syncytiotrophoblasts, but significant differences between laeve cytotrophoblasts and villous cytotrophoblasts. Though these two cytotrophoblasts originated from one common cell in early placental development, they exhibited quite different organellar morphology during placental/chorioamniotic differentiation. Considering previous data, we concluded that chorion laeve cytotrophoblasts were metabolically active cells, similar to villous syncytiotrophoblasts, performing many functions in fetal membrane physiology.

Renal pelvic carcinoma of horseshoe kidney caused systemic metastasis by implantation in prostate

A case is reported of renal pelvic carcinoma of the horseshoe kidney in a 69-year-old man, which showed an interesting metastatic pattern by implantation in the prostate. A few months after transurethral resection of the prostate for benign prostate hyperplasia and extracorporal shock wave lithotripsy for renal stones, the patient complained of severe back pain due to multiple metastatic bone tumors. Autopsy revealed transitional cell carcinoma in the pelvis as well as in the prostate with remarkable vessel invasion. The clinical course and autopsy findings suggested that the systemic expansion of cancer cells from the renal pelvis was caused not only by direct metastasis but also by implantation in the prostate.

Comparison of the long-term effects of oral estriol with the effects of conjugated estrogen on serum lipid profile in early menopausal women

OBJECTIVE

We investigated the long-term effects of oral estriol (E(3)) on serum levels of total cholesterol (t-Cho), high-density lipoprotein cholesterol (HDL-Cho), low-density lipoprotein cholesterol (LDL-Cho), and triglycerides in early menopausal women.

METHODS

We studied 67 healthy early menopausal women who were treated for 48 months with 2.0 mg of E(3) plus 2.5 mg of medroxyprogesterone acetate daily (E(3) group, n=21), 0.625 mg of conjugated estrogen plus 2.5 mg of medroxyprogesterone acetate daily (CE group, n=19), or 1.0 microg of 1alpha-hydroxyvitamin D(3) daily or 1.8 g of calcium lactate containing 250 mg of elemental calcium daily (control group, n=27). The serum levels of t-Cho, HDL-Cho, LDL-Cho, and triglycerides were evaluated at baseline and every 6 months.

RESULTS

After 48 months of treatment, the t-Cho decreased significantly by 4.3+/-2.1% (mean+/-SE) from baseline in the E(3) group, did not change in the CE group (-1.9+/-2.1%), and significantly increased (5.4+/-3.4%) in the control group. The HDL-Cho significantly increased in the CE group (10.7+/-2.4%), but not in the E(3) group (3.8+/-3.3%) or in the control group (-3.6+/-3. 0%). The LDL-Cho significantly decreased in the CE group (-11.4+/-4. 0%), did not change in the E(3) group (-5.2+/-3.6%), and significantly increased in the control group (11.8+/-6.3%). The triglyceride level decreased significantly in the E(3) group (-6. 7+/-4.9%), whereas it significantly increased in the CE group (17. 6+/-11.4%), and did not change in the control group (6.1+/-6.4%).

CONCLUSIONS

Oral E(3) prevented a postmenopausal rise in the t-Cho. Oral estriol did not induce the hypertriglyceridemia that was seen after treatment with conjugated estrogen. Oral E(3) may be a useful alternative therapy in women with hypertriglyceridemia and in women who are reluctant to continue conventional hormone replacement therapy because of uterine bleeding.

Outlining the body contours with scattered photons in lymphoscintigraphy for sentinel nodes

Although lymphoscintigraphy is a useful method of detecting the sentinel nodes of malignancy, conventional lymphoscintigraphy images only the sentinel nodes without revealing their anatomical location. We, therefore, used scattered photons to attempt to outline the body contours of patients with either breast or esophageal cancer. Lymphoscintigraphy was performed 3 to 4 hours after the injection of 111 MBq of 99mTc tin colloid into the peritumoral region. Images were obtained with dual-energy windows of 130 to 150 keV for the primary photons and 70 to 110 keV for the scattered photons. The images constructed from the scattered photons clearly showed the contours of the body, and the fusion images constructed from the primary and scattered photons allowed for easy identification of the location of the sentinel nodes. The results of this study confirm that images obtained from scattered photons on lymphoscintigraphy are helpful in identifying the anatomical location of sentinel nodes.

Emergency cervical cerclage: relation between its success, preoperative serum level of C-reactive protein and WBC count, and degree of cervical dilatation

OBJECTIVE

To assess the relation between the preoperative serum level of C-reactive protein (CRP) and the WBC count and the efficacy of emergency cervical cerclage.

STUDY DESIGN

We retrospectively reviewed the medical records of 17 women (16 singleton pregnancies and 1 twin pregnancy) who underwent emergency cervical cerclage (McDonald technique) between 21 and 26 weeks of gestation. The uterine cervix was dilated >/=3.0 cm and the intact (not ruptured) fetal membranes were visible or protruded into the vagina in all patients. The serum level of CRP and the WBC count were determined preoperatively and postoperatively. Emergency cervical cerclage was considered successful if delivery occurred >/=14 days after the procedure.

RESULTS

Emergency cervical cerclage was successful in 12 women, including the woman with a twin pregnancy, but failed in 5 women. The preoperative serum level of CRP and the WBC count were significantly lower and dilatation of the cervix was significantly less in the success group than in the failure group. Cerclage was successful in all eight patients with cervical dilatation </=4.0 cm, but in only 4 of 9 patients with cervical dilatation >4.0 cm (p < 0. 05). Cerclage was successful in all 11 women with a preoperative serum level of CRP </=4.0 mg/dl and a WBC count </=14,000/ microl compared with 1 of 6 women with either a CRP level >4.0 mg/dl or a WBC count >14,000/ microl (p < 0.01).

CONCLUSION

A preoperative CRP value </=4.0 mg/dl, a WBC count </=14,000/ microl, and cervical dilatation </=4.0 cm were significantly associated with prolongation of pregnancy after emergency cervical cerclage.

A retrospective survey of clinical, pathologic, and prognostic features of adnexal masses operated on during pregnancy

OBJECTIVES

To evaluate retrospective data concerning patients with adnexal masses that were managed surgically during pregnancy and their effect on fetal outcome.

METHODS

Data were reviewed concerning pregnant women who required surgery at our hospital between 1980 and 1997 for an adnexal mass.

RESULTS

In the past 19 years at our hospital a total of 69 Japanese women aged 28.5 +/- 3.4 years (including 2 women with twin pregnancies) were diagnosed with adnexal masses that required surgery. The masses (10.2 +/- 4.5 cm in the largest diameter) were removed at 13.9 +/- 3.7 weeks of gestation. The pathologic features of the 69 lesions were as follows: 33 mature cystic teratomas, 13 functional cysts, 8 mucinous cystadenomas, 6 endometriotic cysts, 4 paraovarian cysts, 3 serous cystadenomas, and 2 malignant neoplasms. Of the 60 patients for whom the outcome of pregnancy was available, 7 (12%) gave birth before 37 weeks of gestation, while 2 (3.3%) experienced spontaneous abortions. There were 3 perinatal deaths among the 60 infants. Two of these 3 infants died due to major anomalies.

CONCLUSIONS

Although larger studies are required for confirmation, our results suggest that an adnexal mass might be associated with an adverse fetal outcome. Surgical intervention at < 24 weeks of gestation per se might not have been related to the adverse outcomes. We emphasize that surgical intervention during pregnancy can be avoided in patients who have ultrasonographically pathognomonic features of benign cystic teratomas, which are the most common neoplasms operated on during pregnancy.

Gated single-photon emission tomography imaging protocol to evaluate myocardial stunning after exercise

This study was designed to apply ECG-gating to stress myocardial perfusion single-photon emission tomography (SPET) for the evaluation of myocardial stunning after exercise. Technetium-99m sestamibi was selected as the perfusion agent and a rest/exercise 1-day protocol was employed. Fourteen patients without coronary stenosis and 33 patients with coronary stenosis were enrolled in the study. We carried out three data acquisitions with ECG-gating: a 15-min data acquisition starting 30 min after the rest injection (AC1), a 5-min acquisition starting 5 min after the stress injection (AC2) and a 15-min acquisition starting 20 min after the stress injection (AC3). Calculation of left ventricular ejection fraction (LVEF) values was performed by means of automatic determination of the endocardial surface for all gating intervals in the cardiac cycle. Measured global EF values in 14 patients without coronary stenosis were 52.3% +/- 7.6% (AC1), 60.6% +/- 8.9% (AC2) and 55.6% +/- 5.6% (AC3), and those in 11 patients with severe ischaemia were 53.6% +/- 8.0% (AC1), 45.6% +/- 12.1% (AC2) and 49.7% +/- 10.7%. The magnitude of the depression of post-stress LVEF relative to the rest LVEF correlated with the severity of ischaemia (r = 0.594, P = 0.002), and segments manifesting post-stress functional depression were associated with ischaemic segments showing reversible perfusion defects. Stress myocardial perfusion SPET with ECG-gating is a feasible method for the evaluation of myocardial stunning as well as exercise-induced ischaemia.

A simple explanation for a case of incompatibility with the reading frame theory in Duchenne muscular dystrophy: failure to detect an aberrant restriction fragment in Southern blot analysis

According to the translational reading frame theory, Duchenne muscular dystrophy (DMD) patients harbor out-of-frame deletion mutations in the dystrophin gene. We identified a Japanese DMD case who appeared to have an in-frame deletion of exons 46-54 that was disclosed by Southern blot analysis using a dystrophin cDNA as a probe. Analysis of dystrophin mRNA in skeletal muscle revealed the presence of an out-of-frame deletion of exons 46-53. In agreement with this result, the region encompassing exon 54 could be amplified from genomic DNA by polymerase chain reaction (PCR). Furthermore, re-analysis by Southern blot using an exon specific probe disclosed that a HindIII fragment containing exon 54 was present at aberrant size, leading to the incorrect conclusion that exon 54 had been deleted. Thus, this particular DMD case does not constitute an exception to the reading frame theory.

Scintigraphic evaluation of myocardial ischaemia using a new fatty acid analogue: iodine-123-labelled 15-(p-iodophenyl)-9-(R, S)-methylpentadecanoic acid (9MPA)

Iodine-123-labelled 15-(p-iodophenyl)-9-(R,S)-methylpentadecanoic acid (9MPA) is a branched fatty acid analogue for myocardial imaging, which has been recently designed for medium washout rates from the myocardium. The purpose of this study was to assess the clinical feasibility of use of 9MPA for the evaluation of myocardial ischaemia. Twenty-one patients were injected with 9MPA at rest, and sequential single-photon emission tomography (SPET) acquisitions were performed 5, 45 and 240 min after administration to calculate washout rates from the myocardium. The findings of 9MPA images were analysed in comparison with those of perfusion images with thallium-201 or sestamibi, coronary angiography and left venticulography. In general, reduction of 9MPA uptake was more remarkable than that of perfusion tracers. The findings of 9MPA early images correlated better with those of exercise perfusion images than with the rest images. Measured washout rates of 9MPA from ischaemic myocardium were significantly slower than those from normal myocardium. The majority of areas with abnormal 9MPA distribution manifested wall motion abnormality, while all areas with normal tracer distribution presented normal wall motion. The detectability of myocardial ischaemia was improved by adding mid and delayed images in six cases. However, both washout and fill-in patterns were encountered in ischaemic lesions, rendering the interpretation of images difficult. In conclusion, the results of this study indicated that 9MPA has acceptable myocardial uptake, that its use is feasible for the detection of ischaemia and that the abnormal distribution of the tracer correlates well with wall motion abnormality reflecting metabolic disorders.

[Evaluation of parathyroid imaging methods with 99mTc-MIBI--the comparison of planar images obtained using a pinhole collimator and a parallel-hole collimator]

Parathyroid scintigraphy with 99mTc-MIBI was performed using two kinds of collimators, namely, a pinhole one and a parallel-hole one, to evaluate which one was more suitable for the detection of hyperfunctioning parathyroid lesions. In the studies using 99mTc source, the pinhole collimator showed better efficiency and spatial resolution in the distance where the parathyroid scan are actually performed. In the phantom study, the nodular activities modeling parathyroid lesions were visualized better on the images obtained using the pinhole collimator. In clinical studies for 30 patients suspicious of hyperparathyroidism, hyperfunctioning parathyroid nodules were better detected when the pinhole collimator was used. In conclusion, the pinhole collimator was thought to be more suitable for parathyroid scintigraphy with 99mTc-MIBI than the parallel-hole collimator.

Secretory low-molecular-weight phospholipases A2 and their specific receptor in bile ducts of patients with intrahepatic calculi: factors of chronic proliferative cholangitis

Intrahepatic calculi is characterized by an intractable course and frequent recurrences, requiring multiple operative interventions. Chronic proliferative cholangitis, an active and long-standing inflammation of the stone-containing bile ducts with the hyperplasia of epithelia and the proliferation of the duct-associated mucus glands, may underlie the complex nature of the disease. In terms of the pathophysiology, interest has been focused on the role of secretory low-molecular-weight phospholipases A2 (sPLA2s) as inflammatory mediators or factors modulating cell functions via their specific sPLA2-receptor, and also on the production and secretion of altered mucin molecules from the inflamed bile ducts. In search of factors involving chronic proliferative cholangitis, the sPLA2 isoforms in the bile such as the pancreatic-type sPLA2 (group IB sPLA2) and the arthritic-type sPLA2 (group IIA sPLA2), were assayed to correlate protein masses of the sPLA2s with alterations in biliary composition. Furthermore, the steady-state messenger RNA (mRNA) levels of the sPLA2s, the membrane-bound sPLA2-receptor, cystic fibrosis transmembrane conductance regulator (CFTR), and mucin core polypeptide (MUC) genes in the bile ducts were assayed by reverse- transcriptase polymerase chain reaction (RT-PCR). Immunoreactive sPLA2-IB and sPLA2-IIA levels were significantly higher in the bile from the stone-containing hepatic ducts (2315 +/- 677 for sPLA2-IB; 281 +/- 42 for sPLA2-IIA ng/dL, mean +/- SEM; n = 20) than in the ductal bile from gallbladder stone patients (609 +/- 92, P <.01; 22 +/- 2, P <.01; n = 24). The increased sPLA2 levels were associated with a concomitant increase in lysophosphatidylcholine, prostaglandin E2 (PGE2), and total mucin concentrations. The affected bile ducts showed an increased mRNA level of sPLA2-IB and sPLA2-IIA compared with the ducts from control subjects, in whom the mRNAs of the sPLA2-receptor and other sPLA2 isoforms, such as groups V and X sPLA2s, were coincidently expressed. Reflecting the increased amounts of total biliary mucins, the affected ducts showed an increase in mRNA levels of CFTR as well as MUC2, MUC3, MUC5AC, MUC5B, and MUC6 compared with the ducts from control subjects. In intrahepatic calculi, an enhanced expression of the sPLA2s and their possible cross-talk via sPLA2-receptor may be of pathophysiological significance for the chronic proliferative cholangitis, in association with the enhanced CFTR expression and the alterations in mucin gene expression in the bile ducts, probably through potentiating arachidonate metabolism with associated biliary alterations favoring growth of preexisting stones and even further progressions.

Effects of long-term ursodeoxycholate administration on expression levels of secretory low-molecular-weight phospholipases A2 and mucin genes in gallbladders and biliary composition in patients with multiple cholesterol stones

Group IIA phospholipase A2 (PLA2), a secretory low-molecular-weight PLA2, may play a critical role in the process of gallbladder mucosal inflammation in multiple cholesterol stones, which in turn may produce biliary pronucleating proteins as well as mucin. On the other hand, ursodeoxycholate (UDC) decreases biliary levels of various pronucleating proteins, possibly because of its membrane-protective effects on the inflamed gallbladder mucosa. To elucidate that beneficial effect of UDC, the expression levels of low-molecular-weight PLA2s, group IIA PLA2 (PLA2-IIA), and group V PLA2 (PLA2-V), and mucin core polypeptide genes in the gallbladders were studied for UDC-treated patients and untreated patients with multiple cholesterol stones. Furthermore, the results were correlated with alterations in biliary composition. With long-term administration of UDC, the PLA2-IIA protein mass (2.7 +/- 0.5 vs. 5.0 +/- 0.4 ng/mg x protein [mean +/- SEM]; P < .01) and steady-state mRNA level, as well as the PLA2-V mRNA level, were significantly decreased in the gallbladders, where the prostaglandin E2 (PGE2) level was concomitantly decreased (190.7 +/- 27.9 vs. 393.6 +/- 55.3 pg/mg x protein; P < .01). In the gallbladder bile, the immunoradiometrically determined PLA2-IIA levels were significantly decreased in the UDC-treated patients (43 +/- 4 ng/dL; P < .01) in comparison with untreated patients (78 +/- 6 ng/dL). Significant decreases were similarly found for total protein, mucin, and free arachidonate concentrations, as well as nucleation activity in the bile. The degree of the changes was found to be rather small in solitary stones. In contrast to the decreased mucin concentration, however, there were no significant changes in the expression levels of mucin core polypeptide genes (MUC1-MUC6) between the UDC-treated and untreated patients. Long-term UDC administration was observed to lower the increased PLA2-IIA protein mass and mRNA level, as well as the PLA2-V mRNA level, in the gallbladders of patients with multiple cholesterol stones, which in turn may be of therapeutic importance in improving the gallbladder mucosal inflammation. Effects of UDC on secretory low-molecular-weight PLA2s as inflammatory mediators may relate to the reported efficacy of UDC treatment in cholesterol gallstone disease.

Assessment of mutations of Ha- and Ki-ras oncogenes and the p53 suppressor gene in seven malignant mesothelioma patients exposed to asbestos--PCR-SSCP and sequencing analyses of paraffin-embedded primary tumors

To examine whether malignant mesothelioma due to asbestos has genetic alterations in the Ha- and Ki-ras oncogenes or in the p53 suppressor gene, we analyzed the point mutations of these genes in paraffin-embedded autopsy samples of the primary tumors of malignant mesothelioma in seven asbestos patients who died from malignant mesothelioma. The genetic analysis was conducted by the polymerase chain reaction-single strand comformation polymorphysms (PCR-SSCP) method in all patients, and through the sequencing of deoxyribonucleic acid (DNA) bases in one patient. No genetic alterations were found in exons 1 or 2 of Ha- and Ki-ras oncogenes, or in exons 5 to 9 of the p53 gene, in any of the patients. Further studies on a larger number of patients are required to reach a definite conclusion concerning the genetic effects of asbestos on malignant mesothelioma.

[Can 99mTc-mercaptoacetyltriglycine (99mTc-MAG3) evaluate the renal function without blood sampling?: consensus report from multicenter study]

A multicenter study was undertaken in Japan to evaluate the correlation between the percentage of renal uptake of 99mTc-mercaptoacetyltriglycine (99mTc-MAG3) estimated by the count-based gamma camera method and the blood clearance of 99mTc-MAG3. Twenty four centers were enrolled and 172 cases were finally analyzed in this study. The renal clearance of 99mTc-MAG3 (TER) was obtained by using a single blood sample taken at 44 min after injection. Comparison of TER and renal uptake provided a coefficient of correlation of 0.874; suggesting that sufficiently accurate quantification of renal function could be obtained from the renal uptake estimate by the gamma camera method. This study also showed that the comparison of renal function might be feasible among patients under the same protocols, although precise and careful consideration is required in each center.

[A case of gastric malignant lymphoma with perforation during chemotherapy]

A 54-year-old male was admitted for loss of appetite lasting for about 3 months. The patient was diagnosed as malignant lymphoma in the stomach invading directly the pancreas, spleen and transverse colon. Chemotherapy, two cycles of VEPA.M, was selected as the initial treatment. After the first cycle of chemotherapy, the patient was discharged temporarily. During the second cycle, on an ambulant basis, the patient suddenly complained of severe pain and distension in the abdomen. Through the X-ray examination of the chest, free air was demonstrated in the bilateral subphrenic spaces. The patient was diagnosed as perforation of the gastrointestinal tract. Subsequently, total gastrectomy was performed. Pathological examination revealed no malignant cells in the stomach wall. It is suggested that the perforation was caused by weakening of the stomach wall following chemotherapy.