Prognostic value of sequencing-based minimal residual disease detection in patients with multiple myeloma who underwent autologous stem-cell transplantation

Background

Most patients with multiple myeloma (MM) are considered to be incurable, and relapse owing to minimal residual disease (MRD) is the main cause of death among these patients. Therefore, new technologies to assess deeper response are required.

Patients and methods

We retrospectively analyzed 125 patients with MM who underwent high-dose melphalan plus autologous stem-cell transplantation (ASCT) to detect MRD in autograft/bone marrow (BM) cells using a next-generation sequencing (NGS)-based method and allele-specific oligonucleotide-polymerase chain reaction (ASO-PCR).

Results

NGS-based method was applicable to 90% and this method had at least one to two logs greater sensitivity compared to ASO-PCR. MRD negative by NGS [MRD^NGS(−)] (defined as <10⁻⁶) in post-ASCT BM cases (n = 26) showed a significantly better progression-free survival (PFS) (96% at 4 years, P < 0.001) and overall survival (OS) (100% at 4 years, P =0.04) than MRD^NGS(+) in post-ASCT BM cases (n = 25). When restricting the analysis to the 39 complete response cases, patients who were MRD^NGS(−) (n = 24) showed a significantly better PFS than those that were MRD^NGS(+) (n = 15) (P =0.02). Moreover, MRD^NGS(−) in post-ASCT BM cases (n = 12) showed significantly a better PFS than MRD^NGS(+) cases (n = 7) where MRD was not detected by ASO-PCR (P = 0.001). Patients whose autografts were negative by NGS-based MRD assessment (<10⁻⁷) (n = 19) had 92% PFS and 100% OS at 4 years post-ASCT. Conversely, the NGS-based MRD positive patients who received post-ASCT treatment using novel agents (n = 49) had a significantly better PFS (P = 0.001) and tended to have a better OS (P= 0.214) than those that were untreated (n = 33).

Conclusions

Low level MRD detected by NGS-based platform but not ASO-PCR has significant prognostic value when assessing either the autograft product or BM cells post-ASCT.

Hypersensitivity Reaction to Carboplatin during Treatment for Ovarian Cancer: Successful Resolution by Replacement with Cisplatin

Development of hypersensitivity reactions to carboplatin (CP) during cancer treatment makes optimal chemotherapy difficult to achieve. Many approaches have previously been used following the development of reactions to CP. We report on a patient with ovarian cancer who developed a hypersensitivity reaction to CP. The patient was successfully treated following replacement of carboplatin with cisplatin.

Acceptance of surrogate end points in clinical trials supporting approval of drugs for cancer treatment by the Japanese regulatory agency

BACKGROUND

This study investigated the historic use of different end points to support approval of drugs for cancer treatment in Japan.

PATIENTS AND METHODS

Anticancer drugs approved between April 2001 and April 2014 were comprehensively investigated using publicly available information.

RESULTS

Before the revision of the guideline for oncology drugs in April 2006 in Japan, >80% of end points supporting approval were response rate and overall survival (OS) was not frequent. After the revision of the guideline in Japan, using OS in pivotal clinical trials applied for approval increased to more than approximately one-third of oncology drugs, although trials with an end point of response rate decreased. Regarding drugs for major cancers including non-small-cell lung cancer, gastric cancer, colorectal cancer, and breast cancer, survival was used as an end point in 44.0%, whereas surrogate end points were used in 56.0%. Exploration of potential factors for using surrogate end points other than survival carried out through determinations of odds ratios and 95% confidence intervals identified 'orphan drug designation in Japan' and 'accelerated approval by the U.S. Food and Drug Administration' as significant factors.

CONCLUSIONS

The revised guideline for oncology drugs in Japan requires the results of phase 3 studies with survival as an end point at the time of new drug application at least for major cancers. The regulatory agency in Japan also accepts surrogate end points as end points supporting approval besides survival; however, the number of surrogate end points has decreased after the revision of the guideline. We consider that accepting surrogate end points in the Japanese regulatory systems is important to approve oncology drugs quickly in Japan.

Anticancer effects of gemcitabine are enhanced by co-administered iRGD peptide in murine pancreatic cancer models that overexpressed neuropilin-1

BACKGROUND

Impaired drug transport is an important factor that reduces the efficacy of anticancer agents against pancreatic cancer. Here, we report a novel combination chemotherapy using gemcitabine (GEM) and internalised-RGD (iRGD) peptide, which enhances tumour-specific drug penetration by binding neuropilin-1 (NRP1) receptor.

METHODS

A total of five pancreatic cancer murine models (two cell line-based xenografts (CXs) and three tumour grafts (TGs)) were treated with either GEM (100 mg kg(-1), q3d × 4) alone or GEM plus iRGD peptide (8 μmol kg(-1)). Evaluation of NRP1 expression in xenografts and 48 clinical cancer specimens was performed by immunohistochemistry (IHC).

RESULTS

We identified a subset of pancreatic cancer models that showed NRP1 overexpression sensitive to iRGD co-administration. Treatment with GEM plus iRGD peptide resulted in a significant tumour reduction compared with GEM monotherapy in CXs, but not remarkable in TGs. Potential targets of iRGD were characterised as cases showing NRP1 overexpression (IHC-2+/3+), and these accounted for 45.8% of the clinical specimens.

CONCLUSIONS

Internalised RGD peptide enhances the effects of co-administered drugs in pancreatic cancer models, its efficacy is however only appreciable in those employing cell lines. Therefore, the clinical application needs to be given careful consideration.

Invasion of carcinoma cells into reconstituted type I collagen gels: visual real-time analysis by time-lapse microscopy

Stromal-epithelial interactions play a critical role in promoting tumorigenesis and invasion. To obtain detailed information on cancer cell behaviors on the stroma and kinetics of cell migration, which cannot be observed by conventionally-used Boyden chamber assays, this study was aimed at analyzing the cell invasion process in vitro using time-lapse microscopic observation. Serum-free conditions and reconstituted type I collagen gels which provided a basal membrane-stroma-like microenvironment were used to first establish a basal condition. Time-lapse microscopic observation for 30 h of cell invasion into the collagen gel revealed kinetic parameters and individualistic behavior of cancer cells. Of breast cancer MDA-MB-231 or MCF-7 cells and colon cancer LS180 or HT29 cells examined, MDA-MB-231 cells most rapidly disappeared from the collagen gel surface under basal conditions. Estrogen-dependent MCF-7 cells disappeared at a rate approximately two times slower than that of MDA-MB-231 cells under serum- and phenol red-free conditions. By the addition of 10 nM β-estradiol to the basal medium, MCF-7 cell invasion was facilitated to a rate similar to that of MDA-MB-231 cells. Microscopic analyses of collagen gel-sections demonstrated that most of the MDA-MB-231 and MCF-7 cells remained within 60 μm from the gel top under basal conditions, which is consistent with the observation obtained using Boyden chambers that no cells could cross the collagen I gel barrier unless 1% fetal calf serum was added to basal conditions. In summary, this study demonstrated future applicability of this method to understand the initial phase of cancer cell invasion processes.

[Lung adenocarcinoma with mixed subtypes which had been followed up for 5-years]

A 63-year-old female was admitted to our hospital for investigation of serum elevation of carcinoembryonic antigen (CEA). She underwent high anterior resection for a rectal cancer 5-years ago. Chest computed tomography (CT) obtained 5-years ago showed a nodule in the right S10, measuring 1.3 x 0.8 cm in size. The nodule was assessed as benign. Chest CT on admission showed the enlarged nodule with a pleural indentation, measuring 2.2 x 1.6 cm in size. Definitive diagnosis could not be established. Since it was difficult to exclude the possibility of malignancy, video-assisted partial resection was performed. Histological examination of the nodule revealed primary adenocarcinoma in frozen sections. Lobectomy with lymph node dissection was performed. The ultimate diagnosis was adenocarcinoma with mixed subtypes. The tumor was classified as stage IA with T1bN0M0. We reported this case because it was a rare slow-growing adenocarcinoma that had a 5-years clinical history before operation.

[Detection of the point of communication by pneumoperitoneum at the surgery for pleuroperitoneal communication]

A 53-year-old male was admitted to our hospital because of dyspnea. Chest radiograph showed a massive right-sided hydrothorax. He was suffering from chronic renal failure and had undergone continuous ambulatory peritoneal dialysis (CAPD) for 8 months. The diagnosis of pleuroperitoneal communication (PPC) was made using injection of indigocarmine into the peritoneal cavity with subsequent pleural detection by thoracocentesis. Injection of contrast media into the peritoneal cavity showed a dome shaped radio-opaque shadow which is located on the diaphragmatic dome followed by the movement of contrast media into the thoracic cavity. Video-assisted thoracic surgery (VATS) was performed under general anesthesia. To identify the point of communication, the method of detecting air leakage was employed. A bleb like lesion on which the hole existed was observed at the center of the diaphragm, and air leakage was identified by filling the thoracic cavity with saline. The pressure in the peritoneal cavity was maintained at 10 mmHg by continuous CO2 inflation. Direct closure was performed to repair the PPC, which succesfully stopped the air leakage. CAPD could be restarted immediately after surgery. No recurrence of hydrothorax has been detected for more than 14 months after surgery.

Antifouling properties of tough gels against barnacles in a long-term marine environment experiment

In the marine environment, the antifouling (AF) properties of various kinds of hydrogels against sessile marine organisms (algae, sea squirts, barnacles) were tested in a long-term experiment. The results demonstrate that most hydrogels can endure at least 2 months in the marine environment. In particular, mechanically tough PAMPS/PAAm DN and PVA gels exhibited AF activity against marine sessile organisms, especially barnacles, for as long as 330 days. The AF ability of hydrogels toward barnacles is explained in terms of an 'easy-release' mechanism in which the high water content and the elastic modulus of the gel are two important parameters.

Antifouling activity of synthetic polymer gels against cyprids of the barnacle (Balanus amphitrite) in vitro

Barnacle (Balanus amphitrite) settlement on synthetic hydrogels with various chemical structures was tested in laboratory assays. The results demonstrated that cyprids settle less or not at all on hydrogels and PDMS elastomer compared with the polystyrene control. The low settlement on gels is most likely due to the 'easy release' of initially attached cyprids from the gel surfaces. This low adhesion of cyprids is independent of surface hydrophilicity or hydrophobicity, and of surface charge. The results also revealed that hydrogels can be categorized into two groups. One group showed an extremely strong antifouling (AF) performance that was independent of the elasticity (E) or swelling degree (q) of the gels. The second group showed relatively less strong AF performance that was E- or q-dependent. In the latter case, E, rather than the q, may be the more important factor for cyprid settlement.

Does eicosapentaenoic acid (EPA) inhibit cerebral vasospasm in patients after aneurysmal subarachnoid hemorrhage?

BACKGROUND

Cerebral vasospasm following subarachnoid hemorrhage (SAH) is a significant cause of morbidity and mortality and recent studies indicate that Rho-kinase plays an important role in the occurrence of such cerebral vasospasm. Eicosapentaenoic acid (EPA), an n-3 polyunsaturated fatty acid, inhibits sphingosylphosphorylcholine (SPC)-induced Rho-kinase activation in vitro, so this study examined whether EPA prevented cerebral vasospasm occurrence after SAH in patients.

METHODS

The trial population was 101 patients with SAH subjected to craniotomy and clip application. EPA was orally administered at a daily dose of 1800 mg EPA from day 4 to day 14 to 73 patients; the other 28 constituted the control group, receiving no EPA.

RESULTS

EPA significantly curtailed both the occurrence of symptomatic vasospasm (14% EPA group, 36% control, P = 0.019) and of cerebral infarction because of cerebral vasospasm (4% EPA group, 29% control, P = 0.001). Moreover, the percentage of patients with a clinically good outcome was significantly higher in the EPA group (85%, P = 0.022) than in control (64%); there were no deaths in the EPA group but three (11%) in control (P = 0.020).

CONCLUSION

These findings suggest EPA inhibits symptomatic cerebral vasospasm and cerebral infarction after SAH and also improves clinical prognosis.

Novel technique for estimating cerebrovascular permeability demonstrates capsazepine protection following ischemia-reperfusion

OBJECTIVE

There has been some discussion as to whether the pial vasculature behaves in the same way as the blood-brain barrier as a whole. Recent studies have shown that capsazepine protects these vessels from the effects of ischemia-reperfusion. We have now used a new method to examine this protection in the whole brain.

METHODS

Horseradish peroxidase concentrations were measured in brain sections and plasma, following starch microsphere induced ischemia, which lasted from 20 to 60 minutes, with 30 minutes reperfusion. The PS product was calculated from the Crone-Renkin equation.

RESULTS

Permeability increase, which depended on duration of ischemia, was considerably greater in the pia than the parenchyma. The increase was also greater in tissue surrounding large radial venules of the cortex. Single vessel studies showed that these differences mirror those between small and large pial venules. Capsazepine treatment protected the parenchymal blood-brain barrier by limiting the post-ischemic permeability increase to about one third, but had no effect on the pia or radial vessel permeability.

CONCLUSIONS

Permeability has been estimated in tissue sections with good spatial resolution using this new technique, which has demonstrated that the TRPV1 receptor plays an important role in the whole brain, not confined to small pial venules.

DARPP-32 expression arises after a phase of dysplasia in oesophageal squamous cell carcinoma

This is the first report to correlate DARPP-32 immunoreactivity (dopamine and cAMP-regulated phosphoprotein, M_r 32 000) to clinicopathological status in human cancer. DARPP-32 is recognised as a neuronal protein. A recent study demonstrated that DARPP-32, and a truncated isoform t-DARPP, are overexpressed in gastric carcinoma during the process of carcinogenesis. The biological function of DARPP-32, however, is still unclear. The purpose of this study was to clarify the roles of DARPP-32 and t-DARPP in oesophageal squamous cell carcinoma (OSCC). Initially, we investigated DARPP-32 and t-DARPP expression in OSCC cell lines by Reverse transcription–polymerase chain reaction and Western blot. DARPP-32 expression was observed in four out of seven (57.1%) cell lines, but t-DARPP expression was not observed in any cell lines. In oesophageal tissue sample, DARPP-32 expression was observed in four out of seven (57.1%) tumour tissues, while t-DARPP was not observed in any tissues. Subsequently, DARPP expression was assessed by immunohistochemistry, using a polyclonal antibody, in tissue sections from 122 patients with primary OSCC. DARPP immunoreactivity was not observed in any normal oesophageal mucous membranes. On the other hand, positive DARPP immunostaining was detected in 37 patients (30.3%) and correlated inversely with pathologic stage (P=0.0284), pT (P=0.0438), pN (P=0.0303) and tumour size (P=0.012). The overall survival rate was worse in patients with DARPP-negative tumours than in patients with DARPP-positive tumours (P=0.0453). Interestingly, DARPP expression was observed in only one out of 45 cases of dysplasia. These observations suggest that DARPP-32 (rather than t-DARPP) expression arises after a phase of dysplasia in OSCC, and that tumours expressing DARPP-32 progress less rapidly than DARPP-32-negative tumours.

Fusion of HIV-1 Tat protein transduction domain to poly-lysine as a new DNA delivery tool

Effective gene therapy depends on the efficient transfer of therapeutic genes to target cells. None of the current technologies, however, satisfy all of the requirements necessary for gene therapy, because the plasma and nuclear membranes of mammalian cells are tight barriers against gene transfer using synthetic delivery systems. The protein transduction domain (PTD) of human immunodeficiency virus type 1 (HIV-1) Tat protein greatly facilitates protein transfer via membrane destabilisation. We synthesised polylysine peptides containing Tat PTD (TAT-pK), or other sequences, and investigated their potential as agents for gene transfer. The synthesised polypeptide TAT-pK retains DNA binding function and mediates delivery of a reporter gene to cultured cells. RGD motif binds with low affinity to alpha integrins which induce cell activation. Two control polypeptides, GGG-pK and RGD-pK, were synthesised and tested, but their gene transfer abilities were weaker than those of TAT-pK. TAT-pK-mediated gene transfer was enhanced in the presence of chloroquine or ammonium chloride, to a greater extent than that of cationic lipid-mediated gene transfer in most cancer cell lines tested. These data suggest that TAT-pK may be a potent candidate delivery vehicle that promotes gene transfer, dependent on the endocytic pathway. We conclude that the TAT-pK/DNA complex is useful as a minimal unit to package therapeutic genes and to transduce them into mammalian cells.

Three cases of small hepatocellular carcinoma presenting as obstructive jaundice

BACKGROUND

Despite improved diagnostic tools, it is often difficult to make a correct diagnosis of small hepatocellular carcinoma (HCC) in patients with obstructive jaundice.

CASE OUTLINES

Three cases of small HCC (<2 cm diameter) presenting as obstructive jaundice are reported. All tumours were initially diagnosed as hilar cholangiocarcinoma based on ultrasonography, computed tomography, cholangiography and angiography. Because of insufficient hepatic function, none of the patients underwent hepatic resection. One patient died 8 months after first admission to our hospital, another died of disseminated intravascular coagulation I month after admission, and the third was treated with hepatic arterial infusion chemotherapy and survived >36 months.

CONCLUSION

It is important to consider HCC in the diagnosis of obstructive jaundice in patients who are predisposed to HCC because of liver cirrhosis and/or chronic viral hepatitis, and have elevated serum alpha-fetoprotein.

Overexpression of hypoxia-inducible-factor 1alpha(HIF-1alpha) in oesophageal squamous cell carcinoma correlates with lymph node metastasis and pathologic stage

The purpose of this study is to investigate the clinical and histopathologic significance of hypoxia-inducible-factor 1alpha (HIF-1alpha) expression in oesophageal squamous cell carcinoma. One hundred and thirty surgically resected specimens of OSCC were immunohistochemically assessed for HIF-1alpha expression with monoclonal antibody. High HIF-1alpha immunostaining was detected in 40 specimens. The percentage of high HIF-1alpha expression cases increased with tumour stage according to pTNM system. High HIF-1alpha expression correlated with pTNM stage, depth of tumour invasion, lymph node metastasis, distant metastasis, lymphatic invasion and positive surgical margin. The overall survival rate was worse in patients with high HIF-1alpha pattern than in patients with low-expression pattern. Univariate analyses identified high HIF-1alpha positivity, depth of tumour invasion, lymph node metastasis, distant metastasis, lymphatic invasion, and a positive surgical margin as risk factors. Multivariate analyses indicated that depth of tumour invasion, lymph node metastasis and positive surgical margin, but not HIF-1alpha, were independent prognostic factors. Survival in patients with a high HIF-1alpha expression was significantly worse than in those with low expression in patient treated with adjuvant therapy.

Caveolin-I overexpression is a favourable prognostic factor for patients with extrahepatic bile duct carcinoma

Extrahepatic bile duct carcinoma (EBDC) is a malignancy well known for its poor prognosis. Some clinicopathological prognostic markers have been proposed, but genetic factors have not been well investigated. We have examined expression patterns of caveolin-1, which has been shown to function as a tumour suppressor in vitro, in EBDC using immunohistochemistry. Normal tissues adjacent to the tumour cells did not show immunoreactivity for caveolin-1. A total of 22 of the 60-carcinoma tissue samples (36.7%) studied were positive for caveolin-1. Caveolin-1 immunostaining negatively correlated with the patient's age and pathological T factor (pT) in a statistically significant manner. Multivariate analysis using Cox's proportional hazards model identified caveolin-1 expression as an independent positive prognostic factor. Thus, our study suggests that caveolin-1 expression may be a useful prognostic marker for EBDC.

Suppression of allergic reaction by lambda-carrageenan: toll-like receptor 4/MyD88-dependent and -independent modulation of immunity

BACKGROUND

Recognition of foreign substances by innate immunity through pattern recognition receptors (PRRs) regulates acquired immunity such as allergic reaction. Because PRRs recognize heterogeneous ligands, daily food intake can potentially regulate immune allergic reaction.

OBJECTIVE

Elucidation of the effect of lambda-carrageenan on allergic reactions was aimed.

METHOD

IFN-gamma and IL-4 was measured in in vitro T cell-stimulated culture. Cytokine production from macrophages in response to lambda-carrageenan was measured as indicator for innate immunity activation. Mice were immunized with OVA in alum to induce specific IgE, and then histamine release was induced by systemic injection of OVA.

RESULTS

Activation of innate immunity by lambda-carrageenan is dependent on Toll-like receptor-4 (TLR4) and MyD88, in which induction of pro-inflammatory cytokines such as TNF-alpha and IL-6 was largely impaired in macrophages from TLR4- and MyD88-deficient mice. Footpad oedema, a model for in vivo inflammatory reactions, was significantly reduced in these mice. Similar to recent evidence showing a preference for the stimulation of Th1 via TLR/MyD88 signalling, lambda-carrageenan showed enhanced IFN-gamma and decreased IL-4 in stimulated T cell cultures. Interestingly, increased IFN-gamma production was still seen in TLR4- and MyD88-deficient splenocytes. Oral administration of lambda-carrageenan to immunized mice successfully decreased OVA-specific IgE, and lambda-carrageenan was also effective in previously immunized mice. Further, serum histamine release upon systemic challenge of OVA was significantly inhibited. Neither OVA-specific IgG1/IgG2a nor cytokine secretion from in vitro cultures were altered, suggesting the involvement of multiple PRRs as demonstrated by TLR4/MyD88-independent IFN-gamma up-regulation. The simultaneous feeding of OVA with lipopolysaccharide abrogated oral tolerance, but lambda-carrageenan was not only devoid of such an effect but was also found to promote oral tolerance in the absence of TLR4.

CONCLUSION

lambda-Carrageenan was suggested to be a useful dietary supplement to ameliorate allergic reactions while maintaining oral tolerance-dependent intestinal homeostasis.

Laparoscopic left hemihepatectomy combined with right hemicolectomy for liver tumor and hemorrhagic diverticulosis

We report a case of laparoscopic left lobectomy combined with right hemicolectomy for cystic liver tumor and hemorrhagic diverticulosis of the ascending colon. Mobilization of the right hemicolon was performed first with a complete laparoscopic method. Then the surgeon's left hand was inserted into the abdominal cavity through a 75-mm incision made in the right upper quadrant, and the hand-assisted method was used for completion after liver resection. After hepatectomy, the right hemicolon was pulled through the hand port incision. The resection and anastomosis were performed extracorporeally to avoid intra abdominal infection. As a hemihepatic inflow control technique, we used the method of en masse occlusion of Glisson's sheath of the left hemipedicle at the bifurcation. The hand facilitates proper traction and exposure of the cut surface, and hemostasis can be achieved by proper application of vascular clips or staplers. The patient had an uneventful, rapid postoperative recovery.

Hand-assisted laparoscopic anatomical left lobectomy using hemihepatic vascular control technique

We report a new approach for laparoscopic anatomical left lobectomy. Although laparoscopic limited resection of the liver has been reported, major liver surgery with a laparoscopic approach remains uncommon. Obstacles to routine laparoscopic surgery on the liver are mainly related to difficulty in retraction with current instrumentation, difficulty in assessing safe margins of resection without the use of tactile sense, and the difficulty of safe parenchymal dissection laparoscopically. We introduce a hand-assisted method that can help in resolving the difficulties and pitfalls associated with laparoscopic liver resection, and in making this surgery safer. The hand is the best atraumatic liver retractor in laparoscopic resection and facilitates the use of laparoscopic ultrasonography. Stable hemostasis can be achieved by proper manual application of vascular clips in case of vascular injury. The hemihepatic inflow control technique used in the present case was the en masse occlusion of Glisson's sheath of the left hemipedicle at the bifurcation. This technique was used exactly the same as in open surgery. Major vessels such as the left hemipedicle and left hepatic vein were dissected by endovascular cutter. The patient had an uneventful, quick postoperative recovery. This technique allows a minimally invasive anatomical major surgery for liver tumors.

Evaluation of the fracture site mechanical properties in vivo by monitoring the motion of a dynamic pin clamp during simulated walking

OBJECTIVE

To monitor pin clamp motion using a displacement sensor over time during weight bearing and to investigate whether this method could contribute to quantitative assessment of the mechanical properties of fracture healing.

METHODS

Patients with a shaft fracture of the tibia were monitored, all of whom were in the stage of dynamization. The hifixator equipped with a ball bearing mechanism was used as a dynamic external fixator. The displacement was recorded versus time during stamping with weight bearing of the patients. The displacement curve had an oscillatory component synchronized with touch down and lift up of the foot, a time-dependent component expressed by shifting of the baseline, and an irreversible component during a non-weight bearing period after stamping. The three components were analyzed with a simple Voigt model.

RESULTS

In all patients, both the amplitude of the oscillatory component and the time-dependent component expressed as retardation time decreased as fracture healing proceeded, and by the time of fixator removal the irreversible component had disappeared.

CONCLUSIONS

The monitoring method could quantitatively evaluate viscoelastoplasticity of the healing fracture site.

RELEVANCE

Until now, there has been few method for assessing the viscoelastic property of the healing fracture site in vivo. Although the method described here involves some assumptions and approximations, it was able to quantitatively assess the viscoelasticity of the healing fracture site.

Selective occlusion with fibrin glue under fistuloscopy: seven cases of postoperative management for intractable complex fistulas

BACKGROUND AND STUDY AIM

Fistula occlusion is not achieved in some fistulas with complex branches. To obtain early fistula closure in such cases, we insert a double-lumen catheter into each fistula branch, with the aid of a guide wire positioned using a small-caliber endoscope, and attempt selective infusion of fibrin glue.

PATIENTS AND METHODS

Following removal of foreign bodies and necrotic granulation, we applied the selective occlusion method under fistuloscopic control to seven intractable external fistulas with complex branches, in which fistula closure had not been obtained by a simple occlusion method (SOM). All the fistulas were complex with more than two branches.

RESULTS

Fistula occlusion was obtained within 2 weeks in six of the seven patients, and there has been no sign of recurrence over a follow-up period of 4 - 59 months (average 29.8 months).

CONCLUSION

Selective occlusion under fistuloscopy is highly effective for intractable external fistulas with complex branches.

[Clinical features and treatment of refractory epilepsy in children]

Clinical features of refractory epilepsy in children are symptomatic localization-related epilepsy, especially frontal lobe epilepsy, the onset in young age less than 3 years-old, and complication of developmental retardation. The treatments usually start with one drug of choice for specific seizure type. In the idiopathic epilepsy group, valproic acid was effective in 82% of the patients with generalized epilepsy and in 45% of localization-related epilepsy while carbamazepine was effective in 71% and 67%, respectively. However, in the refractory group which did not react to the drugs of choice at the initial treatment and continued to have seizures, no specific drugs were effective. Therefore, various kind of drugs, new or old, should be tried in sequence irrespective of the type of seizures. The seizure control was attained only in 10% (in the cases of CZP), and 17% (CLB) in localization-related epilepsy and in 9% (VPA), 12% (NZP) and 20% (ZNS) in generalized one in the refractory group. Although new drugs developed, the patients with refractory epilepsy do not tend to decrease in frequency and overall management including daily life or surgical therapy is mandatory for the children with refractory epilepsy.

Complement plays an important role in gastric mucosal damage induced by ischemia-reperfusion in rats

Ischemia-reperfusion (I/R) of stomach causes gastric mucosal injury. Complement can also cause tissue damage, however its role in gastric I/R injury has not been thoroughly investigated. We evaluated the effect of complement suppression in reducing damage to the gastric epithelium caused by local I/R. Local gastric ischemia was induced by clamping the left gastric artery. The blood-to-lumen clearance of 51Cr-labeled EDTA (51Cr-EDTA) served as an index of epithelial damage. 51Cr-EDTA clearance increased shortly after reperfusion with peak values at 10 min. Intraperitoneal administration of cobra venom factor (CVF; 50 units) prior to I/R, which reduced the serum complement value (CH50) to an undetectable level, remarkably suppressed the 51Cr-EDTA clearance following reperfusion. A monocarboxylic acid derivative of K-76 (K-76 COOH) reduced the CH50 by more than 30% (100 mg/kg) and 60% (200 mg/kg). Rats pretreated with K-76 significantly attenuated the increase in 51Cr-EDTA clearance produced by I/R. These results suggest that complement inhibitor could be used to protect gastric mucosal injury induced by local I/R stress.

Appraisal of intra-arterial infusion of prostaglandin E1 in patients undergoing major hepatic resection report of four cases

In order to reduce risk for postoperative acute liver failure, prostaglandin E1 (PGE1) was administered either from the hepatic artery (HA) or the superior mesenteric artery (SMA) in four high-risk cases undergoing major hepatic resection. Two cases were subjected to HA PGE1 infusion for 3 or 4 days after surgery at a rate of 0.01 microg/kg/min. Both patients had hepatocellular carcinoma (HCC) associated with chronic hepatitis, and ICG R15 was 17.6% and 14.5%, respectively. Right hemihepatectomy and extended right hemihepatectomy were performed. Serum total bilirubin (T. Bil.) peak value was 2.2 mg/100 ml in Case 1 and 2.1 mg/100 ml in Case 2. In Case 1, decreased bile flow was observed immediately after cessation of PGE1. The other two cases were subjected to SMA PGE1 infusion for 5 or 6 days after surgery at the same rate. In Case 3, right hemihepatectomy was performed for HCC on a cirrhotic liver four weeks after right portal vein embolization, in which preoperative ICG R15 was 19.0%. Peak T. Bil level was 3.7 mg/100 ml with uneventful postoperative course. In Case 4 with a huge cholangioma, right trisegmentectomy was performed. Peak serum T. Bil level was 1.7 mg/100 ml in this uneventful postoperative course. In Case 3 and Case 4, portal blood flow, measured by Doppler ultrasonography, was markedly increased by PGE1 infusion. From these results, intra-arterial PGE1 infusion might be useful in prevention of postoperative liver failure after major hepatic resection.

Metastin suppresses the motility and growth of CHO cells transfected with its receptor

We recently reported having identified of the ligand for an orphan G-protein-coupled receptor, hOT7T175, as the gene product (68-121)-amide of the metastasis suppressor gene KiSS-1. We further showed that the ligand, which we named "metastin," inhibits chemotaxis and invasion of Chinese hamster ovary (CHO) cells transfected with hOT7T175 cDNA (CHO/h175) in vitro, and pulmonary metastasis of hOT7T175-transfected B16-BL6 melanomas in vivo. In the present study, we investigated the activity of metastin in CHO/h175 cells in greater detail. Metastin significantly suppressed motility in a chemotaxis assay and wound healing assay at 10-100 nM order concentrations. Two N-terminally truncated peptides, metastin(40-54) and metastin(45-54) inhibited the migration of CHO/h175 cells as potently as metastin itself. Metastin also inhibited the spreading, monolayer growth and colony formation in agar (0.8%) of CHO/h175 cells at 10-100 nM concentrations. These results indicate that metastin is a potent inhibitor of cell motility, leading to suppression of cell growth and antimetastatic activity, and suggest that low molecular chemical compounds could replace its activity as a novel antimetastatic agent.

Cloning of a calcitonin gene-related peptide from genomic DNA and its mRNA expression in flounder, Paralichthys olivaceus

A part of genomic DNA including the calcitonin gene-related peptide (CGRP) gene was cloned from flounder by the genome-walking method. The intron/exon boundary was predicted to occur exactly at the same position as in salmon. The 37-amino acid molecule coded by the region from the intron/exon boundary to the stop codon was preceded by a typical Lys-Arg cleavage signal and included a cleavage/amidation site common to the CGRP of other vertebrates. The predicted amino acid sequence of flounder CGRP had 78%, 78%, 78%, 81%, and 73-78% identity to that of salmon, cod, frog, chicken, and mammalian CGRPs, respectively. Among vertebrates, CGRP is more conserved than calcitonin (CT) because the identity of flounder CT to mammalian CTs is 31-50%. Expression analysis indicated that this hormone is synthesized in the brain, heart, intestine, testis, and ovary. Since we have previously shown that the CGRP receptor is expressed in these tissues, it is suggested that CGRP secreted from each tissue functions in a paracrine or autocrine manner.

Influences of nitrogen sources on usnic acid production in a cultured Mycobiont of the lichen Usnea hirta (L.) Wigg

Effects of the nitrogen sources in the medium for the production of secondary metabolites in lichens were examined. The usnic acid production by a mycobiont of the lichen Usnea hirta was higher in the liquid medium containing ammonium and nitrate ions than in those containing amino acids.

Cytotoxic T cell activity against the peptide, AYRARALEL, from Yo protein of patients with the HLA A24 or B27 supertype and paraneoplastic cerebellar degeneration

OBJECTIVE

To determine a peptide that reacts with cytotoxic T cells (CTL) of patients with paraneoplastic cerebellar degeneration and anti-Yo antibodies with either HLA A24 or B27 supertype.

METHOD

We studied CTL activity of four patients, three were HLA A24-positive and one did not have HLA A24 but had B27 supertype. After an incubation of mononuclear cells with or without peptide and IL-2, CD8-rich fraction was prepared by treatment with Magnetic Cell Sorting system (MACS) twice. CTL activity was calculated by 51Cr release from transfectant, C1RA*2402 as target cells. The peptide-binding assay was examined by flow cytometry.

RESULTS

Two of three HLA A 24-positive patients demonstrated CTL activity against the Yo peptide, AYRARALEL. CTL activity was found to be 19.5% and 11.7% at the effector/target (E/T) ratio of 23:1 and 11:1, respectively. A patient who did not have HLA A24 but had A2 and B27 supertype possessed a CTL activity of 19.4% with 15:1 as E/T ratio. The peptide could bind to HLA A*2402 molecules but not to A*0201.

CONCLUSIONS

We showed CTL activity in two of three Japanese patients with HLA A24 by using HLA A*2402 transfectant cells as the target. In addition, we identified the first Japanese patient who had B27 supertype, and suggested that the same peptide, AYRARALEL, could be recognized by CTL in this patient.

Ontogeny of cholecystokinin-immunoreactive cells in the digestive tract of Atlantic halibut, Hippoglossus hippoglossus, larvae

The appearance and distribution of cholecystokinin (CCK)-producing cells were investigated in the digestive tract of developing larvae of cultured Atlantic halibut, Hippoglossus hippoglossus. The CCK-producing cells were detected immunohistochemically, by use of a primary antiserum against CCK cloned for the Japanese flounder, Paralichthys olivaceus. No CCK-immunoreactive (IR) cells were detected in first-feeding larvae (33 days after hatching, DAH). Forty-five DAH or 12 days after first feeding, there were a few scattered CCK-IR cells in the epithelium of the anterior midgut in about 30% of the examined larvae. All larvae older than 52 DAH had CCK-IR cells in the anterior midgut, particularly frequent in the most anterior region adjacent to the pyloric caeca. No CCK-IR cells were detected in the foregut, the hindgut, or the midgut posterior to the first curvature. The CCK-IR cells spanned the intestinal epithelium from the basal lamina to the lumen and were triangular in shape, with the nucleus in the basal part and a thin apex toward the lumen. The mechanisms controlling release of bile, pancreatic enzymes, and peristalsis during the 12 days between first feeding and the first detection of CCK-IR cells remain to be clarified.

Characteristics of body heat balance of paraplegics during exercise in a hot environment

The purpose of this investigation was to clarify the characteristics of body temperature regulation in paraplegics due to spinal cord injury (SCI) during an arm cranking exercise in a hot environment. Twelve paraplegics with lesions located between Th3 and L1,2 and seven able-bodied subjects (AB) participated in this study. The subjects were exposed to a hot (33 degrees C) or a moderate temperature (25 degrees C) environment for one hour and during the last 10 min of the exposure, the subjects performed arm cranking exercises at an exercise intensity of 40 W. The skin temperatures at the chest, the upper arm, the thigh and the calf, the tympanic membrane temperature (Tty), and the skin blood flow of the thigh (SBFT) were continuously monitored during the experiment. Although no systematical variation was found in the Tty at 25 degrees C, the Tty at 33 degrees C in paraplegics during exercise was significantly greater than that at rest (P < 0.01), which indicated a pronounced heat stress for paraplegics at 33 degrees C. SBFT of paraplegics with high lesions of the SCI remained unchanged during the experiment at 25 degrees C and 33 degrees C, while paraplegics with low lesions in this study showed consecutive increases in SBFT during exercise in both environmental conditions similar to AB. The increased core temperature in paraplegics with high lesions was considered to be due to a lack of sweat response and vasomotor activity in the paralyzed area. On the basis of the findings in this study, it can be suggested that high core temperature without any increment of SBFT may be characterized as body heat balance of paraplegics with high lesions during exercise in a hot environment.

Transplantation of adult rat hippocampus-derived neural stem cells into retina injured by transient ischemia

Neural stem cells are capable of differentiating along multiple central nervous system cell-type lineages, and their use as graft material has provided new strategies for the treatment of neuronal damage. We transplanted adult rat hippocampus-derived neural stem cells into eyes of adult rats that underwent ischemia-reperfusion injury. As control, the cells were also injected into normal rats eyes without ischemic insult. The rats were sacrificed at 1, 2, 4, and 8 weeks, and the eyes were examined histochemically. In eyes with the insult, the transplanted cells were well integrated into the host retinas and expressed Map2ab. In the control, none of the cells migrated into the retina. These results suggest that neural stem cells may be used as donor cells for transplantation to repair ischemic-injured retina.

[Comparison between the anterior chamber configuration in the supine position and that in the prone position in patients with narrow angle]

PURPOSE

To determine whether the anterior chamber configuration of patients with narrow angle is changed in the prone position.

PATIENTS AND METHODS

The study included 16 eyes of 16 patients whose anterior chamber angle was classified as Shaffer 2 or narrower. The prone position test(PPT) and ultrasound biomicroscopy (UBM) were performed on every subject. In the UBM examination, the following parameters were measured both in the supine position and in the prone position: the angle-opening distance at 250 microns from scleral spur(AOD 250), the angle-opening distance at 500 microns from scleral spur(AOD 500), the trabecular-iris angle(TIA), and the anterior chamber depth at the center of the cornea(anterior chamber depth, ACD).

RESULTS

While the intraocular pressure was higher after PPT than before the test, every subject was evaluated as negative for PPT. Mean value of every parameter examined was lower in the prone position than in the supine position(AOD 250: 114 microns, vs. 128 microns, AOD 500: 121 microns vs. 144 microns, TIA: 12.1 degrees vs. 15.5 degrees, ACD: 1966 microns vs. 2002 microns), and the change in ACD was statistically significant (p = 0.013).

CONCLUSIONS

The anterior chamber configuration of patients with narrow angle is changed in prone position. Such a change can occur in patients classified as negative for PPT.