Two Cases of Mechanical Thrombectomy in Patients with Fenestration of the M1 Segment of the Middle Cerebral Artery

M1 fenestration of the middle cerebral artery is rare. We present two patterns of acute thromboembolic conditions in M1 fenestrations treated with mechanical thrombectomy. Case 1 was a male in his 60s presenting with right hemiparesis and aphasia. Angiography showed acute left M1 proximal occlusion; the first direct aspiration revealed two parallel routes, and the second aspiration achieved complete recanalization of the left M1 fenestration. Case 2 was a male in his 70s presenting right hemiparesis and aphasia. Angiography revealed a sudden stair-like narrowing of the left M1 in the intermediate part, and a retrograde blood flow cavity was observed on the upper side of the distal part. Mechanical thrombectomy was performed to diagnose the upper limb occlusion of the left M1 fenestration, and successful recanalization was achieved through direct aspiration. Anatomical variations, such as fenestration, should be considered to reduce complication risks.

A posterior inferior cerebellar artery of C2 transverse foramen level origin that entered the spinal canal via the C1/2 intervertebral space demonstrated by computed tomography angiography

PURPOSE

To describe a case of a posterior inferior cerebellar artery (PICA) of C2 transverse foramen level vertebral artery (VA) origin that entered the spinal canal via the C1/2 intervertebral space.

CASE REPORT

A 48-year-old man with posterior neck pain underwent computed tomography (CT) angiography and selective left vertebral angiography. Arterial dissection was found at the distal V2 segment of the left VA on subtracted CT angiography. The left PICA arising from the VA at the level of C2 transverse foramen was identified on CT angiography with bone imaging. This PICA of extracranial origin entered the spinal canal via the C1/2 intervertebral space, just like a PICA of C1/2 level origin.

DISCUSSION

The origins of PICAs show several variations. PICAs originating at the extracranial C1/2 level VA are relatively rare, with a reported prevalence of approximately 1%. Our patient had a left PICA arising from the VA at the level of the C2 transverse foramen. No similar cases have been reported in the relevant English-language literature. We speculated that the proximal short segment of the PICA arising from the C1/2 level VA regressed incidentally and that the distal segment of the PICA was supplied by the muscular branch of the VA arising from the level of the C2 transverse foramen.

CONCLUSION

We reported the first case of PICA arising from the C2 transverse foramen level VA. CT angiography with bone imaging is useful for identifying a PICA arising from the extracranial VA.

Endovascular Treatment for Acute Ischaemic Stroke Caused by Vertebral Artery Dissection: A Report of Three Cases and Literature Review

Vertebrobasilar artery dissection is an uncommon cause of acute ischaemic stroke (AIS). Optimal endovascular management has not been established. This study aimed to share our experience with endovascular reperfusion therapy for vertebrobasilar artery occlusion due to vertebral artery dissection (VAD). We retrospectively reviewed 134 consecutive patients with AIS who received urgent endovascular reperfusion therapy between November 2017 and November 2019. Three patients diagnosed with VAD were investigated. The evaluation included mechanisms of vertebrobasilar artery occlusion due to VAD, variations in endovascular procedures, and functional outcomes. Dissections at the V3, V4 and extension of V3 to V4 segments were seen in one patient each. The mechanism of AIS was different in each patient: occlusion of the distal non-dissected artery due to an embolus from the dissection site (distal occlusion), haemodynamic collapse of the entire vertebrobasilar artery system due to the arterial dissection itself (local occlusion), or coexistence of distal occlusion and local occlusion (tandem occlusion). The endovascular reperfusion therapy was performed corresponding to the abovementioned mechanisms: mechanical thrombectomy for distal occlusion, stenting for local occlusion, and a combination of thrombectomy and stenting for tandem occlusion. In all three patients, effective recanalization and functional independence (modified Rankin Scale scores of 0–2 at 90 days after the onset) were achieved. Endovascular treatment corresponding to the individual mechanism of AIS may improve patient outcomes.

A dural metastatic small cell carcinoma of the gallbladder as the first manifestation: a case report

Background

A dural metastasis is one of the essential differential diagnoses of meningioma. In general, carcinomas of the breast and lung in females and prostate in males have been the most commonly reported primary lesions of dural metastases. However, dural metastasis of gallbladder carcinoma is extremely rare. Here, we report a unique case of a dural matter metastasis of gallbladder carcinoma as the first manifestation, which was autopsy-defined as small cell carcinoma.

Case presentation

A 78-year-old man came to our hospital complaining of left hemianopia. Brain computed tomography (CT) revealed a sizeable parasagittal dural-based extra-axial tumor. However, the findings for meningioma were atypical by magnetic resonance imaging, suggesting a meningioma mimic. A contrast-enhanced CT scan of the abdomen revealed a large gallbladder carcinoma. The patient opted for the best supportive care and died 2 months later. The post-mortem examination revealed small cell carcinoma in gallbladder carcinoma. Moreover, an immunologically similar carcinoma was detected in the dural metastasis.

Conclusions

To the best of our knowledge, this is the first case of a dural metastasis of gallbladder small cell carcinoma. A systemic examination is essential for clinicians when atypical findings of meningioma are observed, suggesting a meningioma mimic. We present this rare case with a review of the literature.

Takotsubo-like Myocardial Dysfunction in a Patient with Botulism

Botulinum toxin A (BTXA) can disrupt the neuromuscular and autonomic functions. We herein report a case of autonomic system dysfunction that manifested as Takotsubo-like myocardial dysfunction in a patient with botulism. Takotsubo syndrome results in acute cardiac insufficiency, another fatal complication of botulism in addition to respiratory muscle paralysis, particularly in patients with cardiovascular disease.

[Usefulness of Bilateral rSO₂ Monitoring for Predicting Cerebral Hyperperfusion Syndrome after Carotid Artery Stenting]

OBJECTIVE

Cerebral hyperperfusion syndrome(CHS)and cerebral hyperperfusion phenomenon(CHP)induce intracranial hemorrhage and can become critical complications after carotid artery stenting(CAS). The purpose of the present study was to predict and avoid CHS after CAS using bilateral rSO₂ intraoperative monitoring.

METHODS

We retrospectively analyzed 100 consecutive patients who underwent CAS between January 2012 and May 2014 in our institution. We performed continuous bilateral rSO₂ monitoring from anesthetic induction to the day following CAS. CHS was defined as the deterioration of neurological conditions post-CAS, no ischemic changes on post-CAS head CT or brain MRI, an increase in cerebral blood flow(CBF)and cerebral blood volume(CBV), and shortening of the mean transit time(MTT)or time to peak(TTP)on CT perfusion. To compare the CHS/CHP group and non-CHS/CHP group, we defined four parameters:rSO₂ difference(rSO₂ at the endpoint of the procedure-baseline rSO₂), ΔrSO₂ difference(affected side rSO₂ difference-unaffected side rSO₂ difference), rSO₂ ratio(rSO₂ at the endpoint of the procedure/baseline rSO₂), and ΔrSO₂ ratio(affected side rSO₂ ratio/unaffected side rSO₂ ratio).

RESULTS

There were 2 CHS cases(2.2%)and 3 CHP cases(3.3%). In the CHS/CHP group, the ΔrSO₂ difference and ΔrSO₂ ratio were significantly higher than those in the non-CHS/CHP group(p value<0.05);however, no significant differences were found in the affected side rSO₂ difference(p value=0.063)and affected side rSO₂ ratio(p value=0.054)between the groups.

CONCLUSION

We could promptly detect CHS and CHP in all cases by using continuous bilateral rSO₂ monitoring and analysis of the ΔrSO₂ difference and ΔrSO₂ ratio.

[A case of hemifacial paresis in a patient with Lyme neuroborreliosis treated with antibiotics in whom Borrelia meningitis developed]

A 38-year-old man visited our hospital because of hemifacial paresis that developed 2 months after being bit by a tick. We diagnosed idiopathic peripheral facial palsy and gave the patient oral prednisolone and valacyclovir. Although the symptoms completely resolved in about 2 weeks, there was a risk of Lyme neuroborreliosis. The patient therefore received doxycycline (100 mg twice daily) and amoxicillin (1,000 mg 3 times daily) for 14 days. Two months later, he had symptoms of meningitis such as headache and fever accompanied by lymphocytic cerebrospinal fluid pleocytosis. Viral meningitis was diagnosed and treated with parenteral acyclovir. The symptoms of meningitis improved. Tests for serum IgG antibodies against borrelia were positive. We gave the patient a diagnosis of Lyme neuroborreliosis. The patient received intravenous ceftriaxone and had no relapse. It is a rare for meningitis to develop in a patient with cranial neuropathy who received doxycycline. Lyme neuroborreliosis is a rare disease in Japan. Care should therefore be exercised in the diagnosis of Lyme neuroborreliosis and evaluation of the response to treatment.

The safety and efficacy of preoperative embolization of meningioma with N-butyl cyanoacrylate

OBJECTIVE

Preoperative embolization of meningioma is commonly performed; however, there is no consensus on the best embolic material to reduce intraoperative blood loss and surgery time.

METHOD

We retrospectively assessed the safety and efficacy of 56 cases of preoperative embolization of the middle meningeal artery with N-butyl cyanoacrylate (NBCA) in 105 cases of surgery for meningioma. We also defined a blood loss to tumor volume ratio to compensate for bias caused by tumor volume, and analyzed limited cases (the embolized group n = 52, the non-embolized group n = 21) of the convexity, the parasagittal region, the falx, and the sphenoidal ridge.

RESULT

The blood loss to tumor volume ratio was significantly less in the embolized group (p < 0.007). Preoperative embolization could be useful for cases with the external carotid artery as the dominant feeder vessel (p < 0.02); however, the efficacy decreased for cases with an internal carotid artery feeder. Transient complications occurred in four cases (hemiparesis secondary to edema: two cases; intratumoral bleeding: one case; trigeminal nerve disorder: one case). The cases that showed a postoperative increase in edema or intratumoral bleeding were large tumors with the early filling of veins. For such cases, surgeons should pay close attention to slow injection speed and higher NBCA viscosity, not to cause the occlusion of draining vessels.

CONCLUSION

Tumor embolization with NBCA can be safely performed, and the procedure significantly reduces intraoperative blood loss.

Risk factors for coil protrusion into the parent artery and associated thrombo-embolic events following unruptured cerebral aneurysm embolization

OBJECTIVE

Advances in vascular reconstruction devices and coil technologies have made coil embolization a popular and effective strategy for treatment of relatively wide-neck cerebral aneurysms. However, coil protrusion occurs occasionally, and little is known about the frequency, the risk factors and the risk of thrombo-embolic complications.

METHOD

We assessed the frequency and the risk factors for coil protrusion in 330 unruptured aneurysm embolization cases, and examined the occurrence of cerebral infarction by diffusion-weighted magnetic resonance imaging (DW-MRI).

RESULT

Forty-four instances of coil protrusion were encountered during coil embolization (13.3% of cases), but incidence was reduced to 33 (10% of cases) by balloon press or insertion of the next coil. Coil protrusion occurred more frequently during the last phase of the procedure, and both a wide neck (large fundus to neck ratio) (OR = 1.84, P = 0.03) and an inadequately stable neck frame (OR = 5.49, P = 0.0007) increased protrusion risk. Coil protrusions did not increase the incidence of high-intensity lesions (infarcts) on DW-MRI (33.3% vs 29% of cases with no coil protrusion). However, longer operation time did increase infarct risk (P = 0.0003). Thus, tail or loop type coil protrusion did not increase the risk of thrombo-embolic complications, if adequate blood flow was maintained.

CONCLUSION

Coil protrusion tended to occur more frequently in cases of wide-neck aneurysms with loose neck framing. Moderate and less coil protrusion carries no additional thrombo-embolic risk, if blood flow is maintained, which can be aided by additional post-operative antiplatelet therapy.

Risk factors and prevention of guiding catheter-induced vasospasm in neuroendovascular treatment

Mechanically-induced vasospasm often occurs during guiding catheter insertion, occasionally preventing catheter advancement to the desired location. Delicate manipulation would be impossible without the proper positioning of guiding catheters, and vasospasm-induced cerebral hypoperfusion may cause thrombotic complications. From June 2012 to December 2013, we prospectively analyzed 150 endovascular treatment cases, excluding acute cases, for the frequency of vasospasm, risk factors, and countermeasures. The associated risk factors such as the Japanese-style State-Trait Anxiety Inventory (STAI) score; anatomy and devices; and the efficacies of warm compresses, intra-arterial lidocaine/nicardipine, and tranquilizers were analyzed. Groups 1, 2, and 3 comprised 50 patients each with controls, tranquilizer administration, and prophylactic warm compresses/intra-arterial drug injection, respectively. Moderate or severe vasospasm was seen in approximately 40% patients in each group; however, severe vasospasm was absent in Group 3. Mild vasospasm-induced cerebral infarction occurred in one patient each in Groups 1 and 2. Vasospasm during diagnostic angiography [odds ratio (OR) = 10.63; P = 0.01], many ≥ 30° vessel curves [OR = 4.21; P = 0.01], and the high STAI score [OR = 1.84; P = 0.01] were risk factors for severe vasospasm. Although the relationship between anxiety and sympathetic tone remained unclear, tranquilizer administration relieved vasospasm. Warm compresses and the intra-arterial drug infusion were also useful for relieving vasospasm. Prophylactic measures such as a tranquilizer and warm compresses are expected to alleviate vasospasm; in addition, countermeasures such as the intra-arterial injection of lidocaine/nicardipine are effective.

Subdural and intracerebral hemorrhage caused by spontaneous bleeding in the middle meningeal artery after coil embolization of a cerebral aneurysm

Nontraumatic acute subdural hemorrhage (SDH) with intracerebral hemorrhage (ICH) is rare and is usually caused by severe bleeding from aneurysms or arteriovenous fistulas. We encountered a very rare case of spontaneous bleeding from the middle meningeal artery (MMA), which caused hemorrhage in the temporal lobe and subdural space 2 weeks after coil embolization of an ipsilateral, unruptured internal cerebral artery aneurysm in the cavernous portion. At onset, the distribution of hematoma on a computed tomography scan led us to believe that the treated intracavernous aneurysm could bleed into the intradural space. Emergency craniotomy revealed that the dura of the middle fossa was intact except for the point at the foramen spinosum where the exposed MMA was bleeding. Retrospectively, angiography just before and after embolization of the aneurysm did not show any aberrations in the MMA. Although the MMA usually courses on the outer surface of the dura and is unlikely to rupture without an external force, physicians should be aware that the MMA may bleed spontaneously and cause SDH and ICH.

Randomised phase III study of neoadjuvant chemotherapy with methotrexate, doxorubicin, vinblastine and cisplatin followed by radical cystectomy compared with radical cystectomy alone for muscle-invasive bladder cancer: Japan Clinical Oncology Group Study JCOG0209

BACKGROUND

This study aimed to determine the clinical benefit of neoadjuvant methotrexate, doxorubicin, vinblastine, and cisplatin (MVAC) in patients with muscle-invasive bladder cancer (MIBC) treated with radical cystectomy.

PATIENTS AND METHODS

Patients with MIBC (T2-4aN0M0) were randomised to receive two cycles of neoadjuvant MVAC followed by radical cystectomy (NAC arm) or radical cystectomy alone (RC arm). The primary end point was overall survival (OS). Secondary end points were progression-free survival, surgery-related complications, adverse events during chemotherapy, proportion with no residual tumour in the cystectomy specimens, and quality of life. To detect an improvement in 5-year OS from 45% in the RC arm to 57% in the NAC arm with 80% power, 176 events were required per arm.

RESULTS

Patients (N = 130) were randomly assigned to the RC arm (N = 66) and the NAC arm (N = 64). The patient registration was terminated before reaching the initially planned number of patients because of slow accrual. At the second interim analysis just after the early stoppage of patient accrual, the Data and Safety Monitoring Committee recommended early publication of the results because the trial did not have enough power to draw a confirmatory conclusion. OS of the NAC arm was better than that of the RC arm, although the difference was not statistically significant [hazard ratio 0.65, multiplicity adjusted 99.99% confidence interval 0.19-2.18, one-sided P = 0.07]. In the NAC arm and the RC arm, 34% and 9% of the patients had pT0, respectively (P < 0.01). In subgroup analyses, OS in almost all subgroups was in favour of NAC.

CONCLUSIONS

This trial showed a significantly increased pT0 proportion and favourable OS of patients who received neoadjuvant MVAC. NAC with MVAC can still be considered promising as a standard treatment.

UMIN CLINICAL TRIALS REGISTRY IDENTIFIER

C000000093.

Contrast-induced encephalopathy after coil embolization of an unruptured internal carotid artery aneurysm

A 58-year-old woman developed agraphia and mild right hemiparesis approximately one month after undergoing coil embolization of an unruptured left internal carotid artery aneurysm. MRI performed on day 39 post-coil embolization showed multiple lesions in the white matter with signal hyperintensity on T2-weighted and FLAIR images in the left middle cerebral artery territory. The patient's cerebrospinal fluid exhibited an elevated protein level at 46 mg/dL; however, no other findings suggested another underlying disease. Corticosteroids were administered, and, by day 50 post-coil embolization, the clinical findings and abnormal features on MRI had improved. The patient was therefore diagnosed with contrast-induced encephalopathy after coil embolization.

Fabrication of Y2O3-Doped Zirconia/Gadolinia-Doped Ceria Bilayer Electrolyte Thin Film SOFC Cells of SOFCs by Single-Pulsed Laser Deposition Processing

An 8 -mol. % Y₂O₃-doped zirconia/10-mol. % GdO₂-doped ceria (YSZ/GDC) bilayer electrolyte and a Gd_0.5Sr_0.5CoO₃ (GSCO) cathode were deposited by a single-processing, pulsed laser deposition (PLD) method to fabricate anode support cells. No additional heat treatment was needed. Laser frequencies of 10, 20, and 100 Hz were used to deposit bilayer electrolytes between the NiO–YSZ (NiO:YSZ = 60:40 wt. %) anode substrate and the GSCO cathode thin film. The GDC thin film produced at 10 Hz was smooth, well-crystallized, and highly dense. The crystallinity of the GSCO cathode on the GDC was also improved. We concluded the GDC crystallinity affected the crystallinity of the cathode thin film. The resistivity of the YSZ single layer (5.7 μm thickness) was 1.4 times higher than that of the YSZ/GDC bilayer (YSZ 3.0 μm thickness, GDC 2.7 μm thickness) at 600 °C and that of the YSZ-GDC interface became low. The optimum YSZ thickness was found to be approximately 3.0 μm, at which thickness there was effective blocking of the passage of hydrogen molecules and electrons. A cell with a YSZ (3.0 μm thickness, fabricated at 20 Hz)/GDC (5.0 μm thickness, fabricated at 10 Hz) bilayer and GSCO cathode thin film exhibited a maximum power density of 400 mW·cm^–2 at a comparatively low temperature of 600 °C.

Enhanced susceptibility of adriamycin-treated human renal cell carcinoma cells to lysis by peripheral blood lymphocytes and tumor infiltrating lymphocytes

Previous studies indicated that the anticancer agent adriamycin (ADR) could induce activation of cytotoxic T lymphocytes (CTL) and natural killer cells. In this study, we investigated the effect of ADR on the susceptibility of human renal cell carcinoma (RCC) cells to lysis by peripheral blood lymphocytes (PBL) and tumor infiltrating lymphocytes (TIL). Treatment of human RCC cell line ACHN and freshly derived RCC cells with ADR at 1 microg/ml or more for 3 h significantly enhanced their susceptibility to lysis by PBL (P<0.05). This ADR-induced enhancement of susceptibility of RCC cells to lysis by PBL was also observed when freshly derived TIL were used as effector cells (P<0.05). ADR up-regulated the expression of leukocyte function-associated antigen-3 (LFA-3) and intercellular adhesion molecule-1 (ICAM-1), which are critical in the binding and killing of CTL against cancer cells. Of the five fresh RCC cell cultures treated with ADR, LFA-3 was increased in all and ICAM-1 was increased in three of them, respectively (P<0.05). Up-regulation of LFA-3 and ICAM-1 was also observed in ACHN cells treated with two derivatives of ADR, epirubicin and pirarubicin. ADR further significantly increased the bindings of PBL to RCC cells (P<0.05). These findings suggest that treatment of RCC patients with low doses of ADR may sensitize the RCC cells to killing by PBL and TIL and may be a novel immunotherapeutic modality for the treatment of drug-resistant and/or immune-resistant RCC. The inducing of LFA-3 and ICAM-1 by ADR may be involved in the enhancement of susceptibility of PBL and TIL-mediated cytolysis in human RCC cells.

Monoclonal antibody to tumor necrosis factor-related apoptosis-inducing ligand receptor 2 (TRAIL-R2) induces apoptosis in primary renal cell carcinoma cells in vitro and inhibits tumor growth in vivo

Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) triggers apoptosis in a variety of tumor cells through two of its receptors: TRAIL-R1 and TRAIL-R2. We investigate the susceptibility of human renal cell carcinoma (RCC) cells to TRM-1 and HGS-ETR2, 2 human monoclonal agonistic antibodies specific for TRAIL-R1 and TRAIL-R2, respectively. HGS-ETR2 effectively induced apoptotic cell death in 10 of 11 cell cultures, including 2 human RCC cell lines and 9 human primary RCC cell cultures, with a more pronounced effect after preincubation with anti-human IgG Fc. In contrast, TRM-1 was effective in only 1 primary RCC cell culture. The increased effectiveness of HGS-ETR2 for inducing cell death might have been affected by differences in the cell-surface expression of the 2 TRAIL receptors, namely that TRAIL-R2 but not TRAIL-R1 was frequently expressed in most of the RCC cells tested. The activities of caspase-9, -8, -6, and -3 were increased with HGS-ETR2-induced apoptosis, and cell death could be blocked by specific caspase inhibitors for caspase-9, -8, and -3, and the general caspase inhibitor. In vivo administration of HGS-ETR2 with or without cross-linker significantly suppressed tumor growth of subcutaneously inoculated human RCC xenografts in immunodeficient mice. These results suggest the potential utility of TRAIL-R2 antibody as a novel therapeutic agent in RCC.

Prospective evaluation of a “Watchful Waiting” program using initial pathology criteria and PSA-doubling time monitoring for patients with stage T1c prostate cancer

14651

Background: “Watchful waiting (WW)” is becoming a common treatment option for patients (pts) with screening detected prostate cancer. There is, however, no consensus about which pts are suitable for WW and how pts are monitored. Methods: Eligibility criteria: 1) stage T1c prostate cancer pts, 2) age 50–80, 3) serum PSA: 20 ng/ml or less, 4) 1 or 2 positive cores per 6 to 12 systematic core biopsies, 5) Gleason score of 6 or less, 6) 50% or less maximum % cancer occupation in a positive core. The criteria of 4), 5), 6) were confirmed by a central pathologist before pts registration. Registered patients chose either WW or immediate aggressive treatment. In patients who chose WW, serum PSA was monitored every 2 months for 6 months and PSA-doubling time (PSADT) was calculated centrally. Those who showed PSADT 2y and re-biopsy at 13 months fit the initial pathology criteria again. Primary endpoint was “% PSADT > 2 y”, which was defined as proportion of patients who showed PSADT at 6 months > 2 y out of all patients who chose WW. Point estimate of “% PSADT > 2 y” was expected to be higher than 80%. The planned sample size was 100 pts who chose WW, which gives the width of 95% confidence intervals for % PSADT > 2 y within 10%. Results: 134 pts were enrolled from 01/2002 to 12/2003 and 118 pts chose WW while 13 pts chose aggressive treatment (surgery, radiotherapy, hormonal therapy). The initial 6 months’ PSADT could be assessed in 106 patients (measurement point error in 6, early dropout in 6). Of 106 patients, 22 showed PSADT < 2 y (“rapid riser”) while 84 showed PSADT > 2 y. “% PSADT > 2 y” was 71.2% (84/118, 95% CI: 62.1–79.2%). 84 pts have continued WW with median follow-up of 27 months. Neither metastasis nor cancer-death was observed until 06/2005. As to health-related QOL, any domain of SF-36 was not impaired in patients who continued WW at least for 1 year. Conclusion: Our initial selection criteria for WW may include at least 20% of “rapid riser”, hence need further modification. Additionally, it should be confirmed by further follow-up of 84 pts whether eliminating “rapid riser” from WW by initial 6 months’ PSADT is appropriate.

No significant financial relationships to disclose.

Effective treatment of advanced solid tumors by the combination of arsenic trioxide and L-buthionine-sulfoximine

Clinical application of anticancer agents has been often hampered by toxicity against normal cells, so the achievement of their cancer-specific action is still one of the major challenges to be addressed. Previously, we reported that arsenic trioxide (As2O3) could be a promising new drug against not only leukemia but also solid tumors. The cytotoxicity of As2O3 occurred through the generation of reactive oxygen species (ROS), thus inhibiting radical scavenging systems would enhance the therapeutic efficacy of As2O3 provided that normal cells were relatively resistant to such a measure. Here, we report that the combination therapy of As2O3 with L-buthionine-sulfoximine (BSO), which inhibits a critical step in glutathione synthesis, effectively enhanced in vitro growth inhibition effect of As2O3 on all 11 investigated cell lines arising from prostate, breast, lung, colon, cervix, bladder, and kidney cancers, compared with As2O3 treatment alone. Furthermore, this combination enhanced cytotoxicity to cell lines from prostate cancer with less toxicity to those from normal prostate. In vitro cytotoxic assay using ROS-related compounds demonstrated that hydrogen peroxide (H2O2) is a major cytotoxic mediator among ROS molecules. Biochemical analysis showed that combined use of As2O3 and BSO blocked H2O2-scavenging systems including glutathione, catalase, and glutathione peroxidase, and that the degree of this blockade was well correlated with intracellular ROS levels and sensitivity to this treatment. Finally, the effectiveness of the combination therapy of As2O3 with BSO was demonstrated with an orthotopic model of prostate cancer metastasis. We propose that the combination therapy of As2O3 with BSO is a valid means of blockade of H2O2-scavenging system, and that the combination of a ROS-generating agent with an inhibitor of major scavenging systems is effective in terms of both efficacy and selectivity. Furthermore, because the effective doses of both compounds are within clinically achievable range, this report will lead to immediate benefit for the development of a new cancer therapy.

Enhancement of arsenic trioxide-induced apoptosis in renal cell carcinoma cells by L-buthionine sulfoximine

Arsenic trioxide (As2O3) induces clinical remission in acute promyelocytic leukemic patients and apoptosis in various tumor cells in vitro. To develop As2O3-based combination chemotherapy for renal cell carcinoma (RCC), we investigated the cytotoxic effects of As2O3 in combination with chemotherapeutic agents or L-buthionine sulfoximine (BSO), a glutathione (GSH) synthesis inhibitor. Cytotoxicity and synergy were assessed by the MTT assay and isobolographic analysis, respectively. Apoptosis was monitored by Hoechst 33342 staining, flow cytometrical analysis, and DNA fragmentation assay. Treatment of ACHN cells with As2O3 in combination with adriamycin, vinblastine, or 5-fluorouracil induced an antagonistic effect. However, combination treatment with As2O3 and BSO resulted in a synergistic cytotoxic effect. Synergy was also obtained in Caki-1, Caki-2, NC65 cells and freshly derived RCC cells from 6 patients. Simultaneous treatment of ACHN cells with As2O3 and BSO caused significantly more cytotoxicity than the As2O3 first BSO second or the reverse treatment. We further explored the mechanisms underlying this synergistic effect and found that the synergistic cytotoxicity of As2O3 and BSO was realized by inducing apoptosis. This combination markedly decreased intracellular GSH content and GSH-S-transferase (GST) activity. However, neither the intracellular GSH nor GST was decreased by As2O3 with adriamycin, vinblastine, or 5-fluorouracil. Furthermore, the GSH-increasing agents N-acetylcysteine and lipoic acid significantly inhibited the combined cytotoxicity of As2O3 and BSO. These findings indicate that BSO sensitizes RCC cells to As2O3-induced apoptosis through the down-regulation of the intracellular GSH redox system, suggesting the potential application of a combination of As2O3 and BSO for the treatment of RCC.

[Progression from adenocarcinoma to small cell carcinoma of the prostate during endocrinotherapy: a case report]

A 72-year-old man had undergone surgical castration for metastatic prostate cancer (stage D2, the PSA value was 4,300 ng/ml) in September, 1997. He was well clinically for 16 months with undetected level of PSA. However, he presented with general malaise and gross hematuria in May, 1999. After admission to our hospital his condition rapidly deteriorated and he died one week later with respiratory failure. Autopsy revealed extensive involvement of the prostate and bladder by solid tumor with multiple metastases in lungs, liver, spleen, kidneys and bone. Histological examination revealed pure small cell carcinoma of the prostate.

Tumor growth inhibition by arsenic trioxide (As2O3) in the orthotopic metastasis model of androgen-independent prostate cancer

Arsenic trioxide (As2O3) induces clinical remission of patients with acute promyelocytic leukemia. As a novel anticancer agent for treatment of solid cancers, As2O3 is promising, but no in vivo experimental investigations of its efficacy on solid cancers have been done at clinically obtained concentrations. In addition, the cell death mechanism of As2O3 has yet to be clarified, especially in solid cancers. In this study, human androgen-independent prostate cancer cell lines, PC-3, DU-145, and TSU-PR1 were examined as cellular models for As2O3 treatment, and As2O3-induced cell death and inhibition of cell growth and colony formation were evaluated. The involvement of p38, c-Jun NH2-terminal kinase (JNK), caspase-3, and reactive oxygen species (ROS) were investigated in As2O3-induced cell death. Finally, As2O3 was administered to severe combined immunodeficient mice inoculated orthotopically with PC-3 cells to estimate in vivo efficacy. In all three of the cell lines, at high concentrations, As2O3 induced apoptosis and, at low concentrations, growth inhibition. As2O3 activated p38, JNK, and caspase-3 dose dependently. Treatment with the p38 inhibitor and over-expression of dominant-negative JNK did not guard against As2O3-induced cell death. In contrast with partial protection by the caspase-3 inhibitor, the antioxidant N-acetyl-L-cysteine gave marked protection from As2O3-induced apoptosis and eliminated the activation of p38, JNK, and caspase-3, and the generation of ROS. The orthotopic murine metastasis model showed in vivo tumor growth inhibition in orthotopic and metastatic lesions with no signs of toxicity. This study establishes that As2O3 provides a novel, safe approach for treatment of androgen-independent prostate cancer. Generation of ROS as a therapeutic target for the potentiation of As2O3-induced apoptosis also was shown.

Activation of caspase-3 in renal cell carcinoma cells by anthracyclines or 5-fluorouracil

The caspase family of proteases is speculated to have a crucial role in apoptosis. The effect of treatment with adriamycin (ADR), cisplatin (CDDP), 5-fluorouracil (5-FU), vinblastine (VLB), IFN-alpha, or IFN-gamma on the activation of caspase-3, -6, -8, and -9 in renal cell carcinoma (RCC) cells was investigated, to clarify the mechanisms of chemo- and immunotherapeutic agent-mediated apoptosis. Caspase activity was determined by a quantitative colorimetric assay. Apoptosis was monitored by acridine-orange staining assay. Treatment of ACHN cells with CDDP, VLB, IFN-alpha, or IFN-gamma did not activate caspase-3, but its activity was increased 7.2-fold (p = 0.0001) with ADR and 2.8-fold (p = 0.0385) with 5-FU in comparison with control. Furthermore, when the ADR treatment time was shortened from 24 to 8 or 2 h, the same caspase-3 activation occurred. Activation of caspase-3 was also observed in six freshly isolated human RCC cells after the treatment with ADR. Of the six freshly derived RCC cells treated with 5-FU, caspase-3 activity was increased 3.1-fold (p = 0.0051) and 2.4-fold (p = 0.0346) in two of them, respectively. Epirubicin and pirarubicin, compounds closely related to ADR, also respectively enhanced 4.2-fold (p = 0.0052) and 2.8-fold (p = 0.0147) caspase-3 activity in ACHN cells. The activation of caspase-3 observed with a colorimetric assay was confirmed with immunocytochemical analysis using the anti-active caspase-3 mAb, which specifically recognizes the active form of caspase-3. Furthermore, both active caspase-3 and apoptosis triggered by either ADR or 5-FU were inhibited significantly by the general caspase inhibitor Z-VAD-FMK, or a specific caspase-3 inhibitor DMQD-CHO. These findings provide a mechanistic explanation for anthracyclines and 5-FU induced-apoptosis.

Increased intracellular doxorubicin by anti-FAS monoclonal antibody: a mechanism that enhances the cytotoxicity in renal cell carcinoma cells

OBJECTIVES

To investigate the effect of anti-Fas monoclonal antibody (mAb) on the intracellular concentration of doxorubicin in renal cell carcinoma (RCC) cells. Little is known about the influence of anti-Fas mAb on the intracellular concentration of chemotherapeutic agents.

METHODS

The concentration of intracellular doxorubicin was determined by high-performance liquid chromatography. The mRNA and protein levels of multidrug resistance-associated protein gene were evaluated by reverse transcriptase-polymerase chain reaction and immunocytochemistry, respectively.

RESULTS

An increased concentration of doxorubicin inside the cells was found: 2.4-fold in ACHN cells (a human RCC cell line) after treatment with doxorubicin combined with anti-Fas mAb compared with doxorubicin alone. Of the five cases of freshly derived RCC cells treated with doxorubicin and anti-Fas mAb, the intracellular concentration of doxorubicin was increased 2.3 and 2.7-fold in two of them, respectively. Furthermore, both the mRNA and the protein levels of the multidrug resistance-associated protein gene were downregulated after treatment of ACHN cells with anti-Fas mAb. Treatment of ACHN cells with a combination of anti-Fas mAb and doxorubicin resulted in a potentiation of the doxorubicin-mediated cytotoxicity.

CONCLUSIONS

The increased intracellular concentration of doxorubicin by anti-Fas mAb might be one of the mechanisms responsible for the enhancement of doxorubicin-mediated cytotoxicity in RCC cells.

Distinct microsatellite alterations in upper urinary tract tumors and subsequent bladder tumors

PURPOSE

Although synchronous and/or metachronous tumor development is common in urothelial cancer, genetic and biological differences in upper urinary tract and bladder tumors are unclear. We compared the genetic alteration pattern in multifocal disease in patients with upper urinary tract and subsequent bladder tumors, and those with recurrent bladder tumor.

MATERIALS AND METHODS

Using 21 microsatellite markers on the 8 chromosomal arms 2q, 4p, 4q, 8p, 9p, 9q, 11p and 17p we analyzed 34 tumors from 15 patients with upper urinary tract and subsequent bladder disease, and 70 tumors from 22 with recurrent bladder disease.

RESULTS

Judging from the patterns of genetic alterations multifocal tumors were considered to have derived from an identical progenitor cell in 7 of 13 evaluable patients (54%) with upper urinary tract and subsequent bladder tumors, and 16 of 19 (84%) who were evaluable with recurrent bladder tumor. These data confirm the view that seeding or intraepithelial spread is a major mechanism for the multifocal development of urothelial cancer in general. However, a discordant microsatellite alteration pattern in multifocal tumors was observed in 6 of 7 patients (86%) with upper urinary tract and subsequent bladder lesions but in 2 of 16 (13%) with recurrent bladder cancer (p <0.005).

CONCLUSIONS

Our results imply that upper urinary tract neoplasms may be genetically more unstable than bladder neoplasms. The implantation of tumor cells from upper urinary tract to bladder may involve additional and diverse genetic alterations. Furthermore, a considerable number of multifocal upper urinary tract and subsequent bladder lesions may arise independently via field cancerization mechanism. Our study indicates that the factors contributing to multifocal development are different in the 2 groups.

[A case of malignant fibrous histiocytoma arising from the renal capsule]

A 62-year-old man was admitted with a chief complaint of general malaise. Computed tomography showed a large mass adjacent to the parenchyma of the left kidney. The mass was 17 x 13 x 12 cm in size. Preoperative diagnosis was left renal cell carcinoma and left radical nephrectomy was performed. Histopathologically, the tumor was diagnosed as malignant fibrous histiocytoma (MFH), and the tumor was considered to have arisen from the renal capsule. There has been no recurrence for 7 months postoperatively. We review 40 cases of MFH arising from the kidney or the renal capsule in the literature.

Rapid detection of candidate metastatic foci in the orthotopic inoculation model of androgen-sensitive prostate cancer cells introduced with green fluorescent protein

BACKGROUND

An in vivo spontaneous metastatic model using androgen-sensitive prostate cancer cells is needed to the better understanding of prostate cancer progression. Orthotopically inoculated LNCaP cells to SCID mice manifests metastases, but it takes no less than 12 weeks to detect them by conventional methods.

METHODS

The green fluorescent protein (GFP) gene was introduced into LNCaP cells by conventional lipofection technique. Biological characteristics of a subline (LNCaP-GFP) that expressed GFP at high level were compared to those of the parental cells. LNCaP-GFP cells were orthotopically inoculated to the SCID mouse, and metastases to distant organs were chronologically examined under fluorescence microscopy.

RESULTS

There was no difference in growth rates and androgen-responsiveness in vitro between LNCaP-GFP and LNCaP cells. LNCaP-GFP cells inoculated to SCID mice produced prostate specific antigen. Histopathological examination at 12 weeks after inoculation of LNCaP-GFP revealed that metastases were identified as the inoculation of LNCaP cells. Colonies consisting of a few LNCaP-GFP cells, however, were detected in the lung under fluorescence microscopy as early as 4 weeks after inoculation.

CONCLUSIONS

Orthotopic inoculation of LNCaP-GFP to SCID mice may provide a useful tool to investigate the molecular mechanism of progression, in particular the early stage of metastasis, of androgen-sensitive prostate cancer cells.

Use of pretreatment prostate-specific antigen doubling time to predict outcome after radical prostatectomy

The objective of this study was to better understand the implications of the rate of prostate-specific antigen (PSA) changes in prostate carcinoma. We retrospectively calculated PSA doubling times prior to surgery in 62 patients with prostate carcinoma. The calculated values were compared with final pathologic findings and with rates of PSA failure after surgery. PSA values increased during the period of observation in 82.3% of the patients, whereas 17.7% had levels that remained stable. The median calculated PSA doubling time in those with increasing levels was 25.8 months, with doubling times </=24 months observed in 37.1% of the patients. Stage pT3 disease was more common in patients with PSA doubling times of </=36 months than in those with doubling times >36 months (P=0.02). Biochemical failure was more common in patients with rapid PSA doubling times (P<0.01). The calculated PSA doubling time prior to radical surgery is significantly associated with the final pathologic findings. Early PSA failure is more common in patients with rapid PSA doubling times prior to radical surgery. Prostate Cancer and Prostatic Diseases (2000) 3, 269-274

Suppression of pulmonary metastasis using adenovirally motility related protein-1 (MRP-1/CD9) gene delivery

Previously we showed that MRP-1/CD9 might prevent tumor metastasis by suppression of cell motility and invasion of tissue barriers. The present study explored the possibility of preventing metastasis of mouse melanoma BL6 by expression of MRP-1/CD9 through gene transfer. A replication-deficient adenovirus vector was used for the in vivo transfer of MRP-1/CD9 cDNA. Intratumor injection of an adenovirus vector (rAd-MRP-1/CD9) expressing MRP-1/CD9 resulted in a 73.7% reduction in the number of pulmonary metastases of mice and the median survival time of mice treated with rAd-MRP-1/CD9 was significantly longer than those treated with the rAd-beta-gal vector (103.2 approximately plus;8.5 days vs 71.2 approximately plus;5.2 days, P<0.001 respectively). These results support the expression of MRP-1/CD9 through gene transfer as a therapeutic strategy for preventing metastases and prolonging survival, and support the feasibility of gene transfer in a clinically relevant setting.

[A study on parameters to predict tumor volume for stage T1c prostate cancers of Gleason score 6 or less]

The number of cases of stage T1c prostate cancer has dramatically been increasing since the introduction of PSA as a screening test. The patients with T1c prostate cancer are usually treated by radical prostatectomy. In this group, however, some cancers are of small tumor volume and with a Gleason score of less than 7. These cancers are considered to be good candidates for watchful waiting management. We have investigated 40 patients with T1c prostate cancer treated by radical prostatectomy between 1996 and 1998. All 9 patients harboring tumors of Gleason score 7 or greater had tumors larger than 0.5 cm3. We have investigated PSA-related parameters including total PSA (PSA), PSA density (PSAD), free PSA, and % free PSA in 31 patients with T1c cancers of Gleason score 6 or less in order to clarify good preoperative predictors of tumor volume. We compared the distribution of PSA, PSAD, free PSA, and % PSA between the larger and smaller tumor groups. There was no significant difference in PSA, PSAD, or free PSA value. The small tumor group had a greater mean % free PSA than the larger tumor group (23.27 versus 11.88, p = 0.007). Areas under receiver operating characteristic curves were 0.715, 0.794, 0.636, and 0.842 for PSA, PSAD, free PSA and % free PSA. In stage T1c prostate cancer of Gleason score 6 or less, % free PSA may be the most useful preoperative predictor for tumor volume of 0.5 cm3 or greater.

Increased risk of prostate cancer and benign prostatic hyperplasia associated with a CYP17 gene polymorphism with a gene dosage effect

The CYP17 gene (CYP17) codes for the cytochrome P450c17alpha enzyme, which mediates two key steps in the sex steroid synthesis. There is a polymorphism (a T-to-C substitution) in the 5'-untranslated region, which may influence the transcription level of CYP17 mRNA. There is a continuing controversy as to whether the variant allele is associated with a subset of breast cancer or polycystic ovary syndrome. In prostate cancer research, there are contradictory data concerning the CYP17 risk allele. We explored the association between CYP17 polymorphism and a risk of prostate cancer or benign prostatic hyperplasia (BPH) in a Japanese population. This study included 252 prostate cancer patients, 202 BPH patients, and 131 male controls. A 451-bp fragment encompassing the polymorphic site was amplified by PCR, treated with restriction enzyme MspA1, and electrophoresed on an agarose gel. The MspA1-undigested allele with the published sequence and the MspA1-digested variant allele were designated as A1 and A2, respectively. There was a significant difference (P < 0.05) in the genotypes between prostate cancer patients and male controls, and between BPH patients and male controls. Men with the A1/A1 CYP17 genotype had an increased risk of prostate cancer [odds ratio (OR), 2.57; 95% confidence interval (CI) = 1.39-4.78] and BPH (OR, 2.44; 95% CI = 1.26-4.72) compared with those with the A2/A2 genotype. Men with the A1/A2 genotype had an intermediate increased risk of prostate cancer (OR, 1.45; 95% CI = 0.84-2.54) and BPH (OR, 1.60; 95% CI = 0.89-2.87) compared with those with the A2/A2 genotype. The trend of an increasing risk of prostate cancer and BPH with an increasing number of the A1 allele was statistically significant (prostate cancer versus male control, P = 0.003; OR, 1.57; 95% CI = 1.16-2.12; BPH versus male control, P = 0.008; OR, 1.55; 95% CI = 1.12-2.13). There was no significant association between the CYP17 genotype and the tumor status (grade and stage) of prostate cancer. Our results suggest that the A1 allele of the CYP17 polymorphism is associated with an increased risk of prostate cancer and BPH, with a gene dosage effect. However, the CYP17 genotype does not seem to influence the disease status in prostate cancer.

[Long-term clinical results of 5 cases of urachal carcinoma]

Five cases of urachal carcinoma experienced in our hospital during the past 20 years are reported. Surgical resection is considered as the first treatment option of this disease, and other therapies to be less beneficial. Complete surgical extirpation and detection of recurrence in the early stage are considered to be important since local recurrence occurs frequently. We enforced the bladder preserving operation for 4 patients with urachal carcinoma except for 1 case with peritonitis carcinomatosa in the initial diagnosis, and multiple surgical treatment was performed again for 2 patients with recurrence. The bladder was preserved with no evidence of malignancy in three patients for 24, 19 and 5 years, respectively. In the initial management of urachal carcinoma, we believe that bladder-preserving surgery should be considered in selected cases though close follow-up is demanded. Herein, we also report the immunohistochemical study of paraffin-embedded specimens using anti-CEA, CA19-9, CA125 and p53 monoclonal antibodies. The positive reaction was observed in 100% (5/5) for CEA, 80% (4/5) for CA19-9, and 20% (1/5) for CA125. These results suggest that CEA may be a useful marker in the diagnosis of this neoplasm and early detection of its recurrence. Nuclear accumulation of p53 was observed in 80% (4/5), but it did not correlate with the disease progression.

Molecular diagnosis of metastatic origin in a patient with metachronous multiple cancers of the renal pelvis and bladder

It is not uncommon for patients with urothelial cancer to have synchronous and metachronous multifocal invasive tumors of the bladder and upper urinary tract. If a metastatic lesion becomes evident in such a patient, the origin of the metastasis is often not determinable using conventional histopathologic examination of the surgical or autopsy specimen. Here, we report a patient in whom the clonal relationship among the histologically undistinguishable multifocal urothelial cancers and metastatic tumors could be clarified by molecular genetic analysis. Furthermore, the potential role for each genetic alteration in the multifocal and metastatic tumor development and the treatment efficacy for each multifocal tumor were also clearly demonstrated.

p21(WAF-1/CIP-1), a downstream regulator of functional p53 loss, in transitional cell carcinoma of urothelium

OBJECTIVES

The expression of p21(WAF-1/CIP-1), a downstream regulator of p53, is a universal cycline-dependent kinase inhibitor. The aim of this study is to determine whether p21 expression could be used as a prognostic marker in urothelial carcinomas.

METHODS

By use of immunohistochemistry, we examined the expression of p21(WAF-1/CIP-1) in 60 patients with urothelial carcinomas and compared the results with the status of nuclear p53 and mdm2 accumulation, expression of type IV collagen in the basement membranes and upregulation of metalloproteinases (MMP-1, MMP-2, MMP-9).

RESULTS

p21(WAF-1/CIP-1) immunoreactivity was observed in 51.7% of the tumors, and in only 39% of the tumors with functional p53 loss (nuclear accumulation of p53 and/or mdm2). p21(WAF-1/CIP-1) overexpression was not associated with grade and stage of the tumors and presence or absence of concomitant CIS. Moreover, p21(WAF-1/CIP-1) overexpression was not associated with upregulation of metalloproteinases or destruction of type IV collagen of basement membranes.

CONCLUSIONS

Our results suggest that p21(WAF-1/CIP-1) expression is regulated by both p53-dependent and independent pathways and is not related to grade, stage or potential markers of invasion in urothelial carcinomas.