A case of dupilumab combination therapy for exacerbation of atopic dermatitis in a patient with eosinophilic granulomatosis with polyangiitis treated with mepolizumab

We report a 60-year-old male with eosinophilic granulomatosis with polyangiitis (EGPA) complicated with atopic dermatitis (AD). The patient was initially treated with prednisolone, cyclosporine A, and mepolizumab (MEPO). Due to worsening skin symptoms after prednisolone tapering, dupilumab (DUP) was added as an adjunctive therapy for AD confirmed by skin biopsy. The combination therapy of MEPO and DUP resulted in rapid improvement of skin symptoms, suggesting it may be an effective therapeutic option for patients with EGPA and AD. This case report emphasises the importance of a multidisciplinary approach in treating complex diseases such as EGPA and AD.

Efficacy and safety of single-dose ivermectin in mild-to-moderate COVID-19: the double-blind, randomized, placebo-controlled CORVETTE-01 trial

Background

To investigate whether ivermectin inhibits SARS-CoV-2 proliferation in patients with mild-to-moderate COVID-19 using time to a negative COVID-19 reverse transcription-polymerase chain reaction (RT-PCR) test.

Methods

CORVETTE-01 was a double-blind, randomized, placebo-controlled study (August 2020-October 2021) conducted in Japan. Overall, 248 patients diagnosed with COVID-19 using RT-PCR were assessed for eligibility. A single oral dose of ivermectin (200  μg/kg) or placebo was administered under fasting. The primary outcome was time to a negative COVID-19 RT-PCR test result for SARS-CoV-2 nucleic acid, assessed using stratified log-rank test and Cox regression models.

Results

Overall, 112 and 109 patients were randomized to ivermectin and placebo, respectively; 106 patients from each group were included in the full analysis set (male [%], mean age: 68.9%, 47.9 years [ivermectin]; 62.3%, 47.5 years [placebo]). No significant difference was observed in the occurrence of negative RT-PCR tests between the groups (hazard ratio, 0.96; 95% confidence interval [CI] 0.70-1.32; p = 0.785). Median (95% CI) time to a negative RT-PCR test was 14.0 (13.0-16.0) and 14.0 (12.0-16.0) days for ivermectin and placebo, respectively; 82.1% and 84% of patients achieved negative RT-PCR tests, respectively.

Conclusion

In patients with COVID-19, single-dose ivermectin was ineffective in decreasing the time to a negative RT-PCR test.

Clinical Trial Registration

ClinicalTrials.gov, NCT04703205.

[Treatment Results and Strategies for Early Gastric Cancer Patients Aged 80 Years or Older-How Should We Deal withNon -Curative ESD Cases ?]

With the aging population, the number ofearly gastric cancer patients aged 80 years or older is increasing. We clarified the outcome ofgastrectomy among early gastric cancer patients aged 80 years or older and examined the significance ofadditional gastrectomy for non-curative ESD cases. 1 ) Surgical outcomes in 90 cases ofearly gastric cancer patients aged 80 years or older with gastrectomy were analyzed. Gastrectomy was performed for patients up to 88 years of age and 84 cases (93.3%)were pStageⅠA. Three years and 5 years survival rates were 83.9% and 60.4%, respectively. The causes ofdeath included other disease in 28 cases, other cancer in 4 cases, and death associated with hospital stay in 1 case. 2 ) There were 28 non-curative ESD cases, including 6 T1a, 9 T1b1, and 13 T1b2. Among them, 8 additional gastrectomies were performed, but none were lymph node metastases and cancer residue at the proper muscle layer was identified in only 1 case. Three years and 5 years survival rates ofthe additional gastrectomy group were 100% and 60%, respectively. Although 2 years survival rate ofthe group without additional gastrectomy was 83.3%, there were no deaths due to gastric cancer. In elderly patients with early gastric cancer, considering the increasing the proportion deaths due to other diseases and the decreased quality of life after gastrectomy, the usefulness of additional gastrectomy for non-curative ESD is limited.

Detection of Phomopsis sclerotioides in Commercial Cucurbit Field Soil by Nested Time-Release PCR

A polymerase chain reaction (PCR)-based molecular method to detect Phomopsis sclerotioides in soil was developed using a species-specific primer pair. To improve sensitivity of the detection, three PCR techniques were used; namely, nested PCR using the primer pair internal transcribed spacer (ITS)1 and ITS4, time-release PCR using two different DNA polymerases (recombinant Taq and AmpliTaq Gold), and fluorescent PCR to obtain fluorescent-labeled PCR products that can be analyzed by capillary electrophoresis. The latter two techniques were combined and termed nested time-release fluorescent (NTRF)-PCR. The minimum concentration of DNA required to obtain species-specific PCR products successfully was 50 fg/μg. Using the NTRF-PCR method, the fungus could be detected in sandy soil that was artificially infested at a density of 10 CFU/g. The pathogen was detected in most soil samples collected from commercial cucumber fields in which visual disease symptoms had appeared, and even in samples collected from fields where visual disease symptoms had not appeared. To prevent the invasion and establishment of root-inhabiting pathogens such as P. sclerotioides, it is critical to detect the fungus in soil as soon as possible after its introduction into a cucumber-growing region.

Promising survival for patients with glioblastoma multiforme treated with individualised chemotherapy based on in vitro drug sensitivity testing

We retrospectively investigated the efficacy and feasibility of individualised chemotherapy based on in vitro drug sensitivity testing (DST) for patients with glioblastoma multiforme. A total of 40 consecutive patients with glioblastoma multiforme (GM) were enrolled into this study between January 1995 and December 2000. The flow cytometric (FCM) detection of apoptosis was used to determine the in vitro sensitivity of tumour cells obtained at surgery to 30 different kinds of anticancer agents. From the results of FCM assay, an in vitro best regimen was prospectively selected. All the patients concurrently received the individualised chemotherapy with the in vitro best regimen and 60 Gy of conventional radiation therapy. Of the 31 assessable patients, eight patients (26%) achieved partial response, and 20 patients (65%) had stable disease. The median survival time was 20.5 months. The individualised chemotherapy based on in vitro DST was associated with favourable survival time for the patients with GM compared with the reported results of conventional therapy regimens. The present result suggests that the currently available anticancer agents could be effective against GM when used in individualised chemotherapy.

Induction of immunity in peripheral tissues combined with intracerebral transplantation of interleukin-2-producing cells eliminates established brain tumors

Cytokine gene therapy for the induction of potent immune responses against central nervous system tumors has proven to have significant potential. However, this strategy needs improvement in the process of antigen presentation and/or insufficient recruitment of immunocompetent cells to achieve successful eradication of established brain tumors. We investigated the therapeutic potential of induced systemic immunity in peripheral tissues combined with interleukin-2 (IL-2) production in the vicinity of brain tumors to treat established brain tumors. Sequential magnetic resonance image monitoring showed that the combinatory therapy consisting of intracerebral (i.c.) transplantation of IL-2-producing rat gliosarcoma 9L (9L/IL-2) cells and s.c. vaccination using irradiated 9L or 9L/IL-2 cells could cure 9L-bearing rats, whereas either the i.c. injection of 9L/IL-2 cells or the s.c. vaccination produced little or marginal antitumor effects, respectively. Xenogeneic murine neuroblastoma cells secreting IL-2 could substitute for 9L/IL-2 cells, producing significant antitumor effects in the vaccinated rats. Tumor-specific cytotoxic activity was induced in the vaccinated rats but not fully in the rats treated only with i.c. injection of 9L/IL-2 cells. Immunohistochemical analysis revealed that a number of CD4(+) and CD8(+) T cells infiltrated into the brain tumors which were treated with the combinatory therapy. The level of cell infiltration was similar to that found in s.c. 9L/IL-2 tumors which were subsequently rejected. In contrast, the brain tumors treated with either i.c. transplantation of 9L/IL-2 cells or the s.c. vaccination showed only moderate infiltration of T cells. The combinatory strategy, i.c. grafting of IL-2-producing cells, and s.c. immunization of irradiated whole tumor cell vaccine, is, thus, effective for recruiting activated T cells into the brain tumor site and could be a potential therapy for brain tumors.

High linear energy transfer carbon radiation effectively kills cultured glioma cells with either mutant or wild-type p53

PURPOSE

A mutation in the p53 gene is believed to play an important role in the radioresistance of many cancer cell lines. We studied cytotoxic effects of high linear energy transfer (LET) carbon beams on glioma cell lines with either mutant or wild-type p53.

METHODS AND MATERIALS

Cell lines U-87 and U-138 expressing wild-type p53 and U-251 and U-373 expressing mutant p53 were used. These cells were irradiated with 290 MeV/u carbon beams generated by the Heavy Ion Medical Accelerator in the National Institute of Radiologic Science or X-rays. A standard colony-forming assay and flow cytometric detection of apoptosis were performed. Cell cycle progression and the expression of p53, p21, and bax proteins were examined.

RESULTS

High LET carbon radiation was more cytotoxic than low LET X-ray treatment against glioma cells. The effects of the carbon beams were not dependent on the p53 gene status but were reduced by G(1) arrest, which was independent of p21 expression. The expression of bax remained unchanged in all four cell lines.

CONCLUSION

These results indicate that high LET charged particle radiation can induce cell death in glioma cells more effectively than X-rays and that cell death other than p53-dependent apoptosis may participate in the cytotoxicity of heavy charged particles. Thus, it might prove to be an effective alternative radiotherapy for patients with gliomas harboring mutated p53 gene.

Efficacy of the bystander effect in the herpes simplex virus thymidine kinase-mediated gene therapy is influenced by the expression of connexin43 in the target cells

Tumoricidal "bystander effect" observed in the herpes simplex virus thymidine kinase (HSVtk)/ganciclovir (GCV) gene therapy was studied between different rat glioma cell lines (9L and C6 cells) under both in vitro and in vivo conditions. For that purpose, mixed populations of wild-type cells (9Lwt and C6wt) and respective HSVtk gene-transduced cells (9Ltk and C6tk) were examined for their sensitivity to GCV. A potent in vitro bystander effect was observed in 9Lwt/9Ltk and 9Lwt/C6tk combinations but not in C6wt/9Ltk and C6wt/C6tk combinations. In vivo bystander effect studied in a subcutaneous tumor model in athymic nude mice was also potent in 9Lwt/9Ltk and 9Lwt/C6tk combinations. Because the expression of connexin43, a major protein in the connexin family gene products, in 9L cells is much higher than that in C6 cells, the results suggest that the amount of connexin in target (wild-type) cells but not in effector (HSVtk gene-bearing) cells is important for the generation of the bystander effect. This hypothesis was further confirmed by the observation that in vitro bystander effect in C6wt/C6tk combination was potentiated by transduction of the connexin43 gene to the target cells.

Immunological responsiveness to interleukin-2-producing brain tumors can be restored by concurrent subcutaneous transplantation of the same tumors

The central nervous system shows tolerance for activated host immune reactions, and this relative unresponsiveness may lessen the efficacy of an immunotherapy for brain tumors. Using interleukin-2 (IL-2)-producing 9L rat gliosarcoma cells (9L/IL-2), we examined whether secretion of IL-2 from subcutaneous (s.c.) and/or intracerebral (i.c.) tumors can elicit augmented immunological responses to brain tumors. Syngeneic rats could reject 9L/IL-2 cells inoculated s.c., but developed 9L/IL-2 brain tumors by i.c. inoculation. The growth of i.c. 9L/IL-2 tumors was, however, significantly retarded compared with that of i.c. wild-type tumors. The growth of i.c. wild-type tumors was significantly suppressed when the rats concurrently received 9L/IL-2 cells s.c. Moreover, most of the rats that were inoculated i.c. with 9L/IL-2 cells did not develop brain tumors when concurrently injected s.c. with 9L/IL-2 cells. Immunohistochemical analysis on i.c. 9L/IL-2 tumors, when the rats were concurrently inoculated s.c. with 9L/IL-2 cells, revealed that migration of CD4+ or CD8+ T cells, monocytes/microglias, and macrophages was markedly augmented to a similar level as found in the s.c. 9L/IL-2 tumors. These results showed that systemic immune responses to brain tumor were induced in an immunologically privileged site by concurrent s.c. inoculation of the same tumors that produce IL-2. The present study may also raise the possibility of a therapeutic strategy for brain tumors by the combinatory expression of IL-2 gene using s.c. immunization followed by direct gene transfer into brain tumors.

Alteration of CDKN2/p16 in human astrocytic tumors is related with increased susceptibility to antimetabolite anticancer agents

A slowly proliferating cell fraction in tumors shows reduced sensitivity to cell cycle-dependent anticancer agents. To understand the molecular basis of drug resistance observed in brain tumors, we examined the relationship between alteration of p16, a cyclin dependent kinase inhibitor whose functions are frequently lost in many human gliomas, and chemosensitivity of tumor cells to various kinds of anticancer agents. Alterations of the p16 gene that include mutation(s) and homozygous deletion as well as p16 protein expression level, were examined in 56 specimens of astrocytic tumors. Their in vitro chemosensitivities to 30 kinds of anticancer agents were analyzed with flow cytometry which detects drug-induced cell death. We found that the alterations were correlated with increased sensitivity to antimetabolite anticancer agents but not with other kinds of agents, including alkylating agents, antibiotics, topoisomerase inhibitors and antimicrotubule agents. The present results suggest that p16 plays a role in determining chemosensitivity of brain tumors, depending on pharmacological mechanisms of anticancer agents. Proper understanding of the molecular machinery which regulates the chemosensitivity may contribute to the choice of anticancer agents for individual patients.

The p73 gene is not mutated in oligodendrogliomas which frequently have a deleted region at chromosome 1p36.3

An allelic loss of the chromosome 1p36 region is frequently found in oligodendrogliomas, which suggests the presence of putative tumor suppressor gene(s) in the region. Since the p73 gene, which encodes a protein with significant homology with p53, is mapped to the 1p36.33 region, we examined genetic alterations of the p73 gene in oligodendrogliomas. We screened 10 specimens for mutation throughout the p73 coding regions by polymerase chain reaction (PCR)-single strand conformation polymorphism analysis and by sequencing aberrantly migrated PCR products. We found several polymorphic nucleotide changes, but no somatic mutations that caused an amino acid change. The p73 gene is thus unlikely to be a tumor suppressor gene for oligodendrogliomas.

Neuroradiological characteristics of pineocytoma and pineoblastoma

We reviewed neuroradiological images in two histologically proven cases of pineocytoma and three of pineoblastoma to delineate the characteristic features of these rare tumours. CT revealed isodense or slightly hyperdense masses with central or peripheral calcification; enhancement with contrast medium tended to be homogeneous in pineocytomas and heterogeneous in pineoblastomas. In the pineocytomas, T1-weighted images revealed rounded, sometimes or slightly lobulated low-signal masses with strong, homogeneous contrast enhancement. Their margin was clear, without invasion of adjacent structures. In the pineoblastomas, however, T1-weighted images revealed multilobulated tumours with heterogeneous contrast enhancement. All three pineoblastomas had poorly defined margins with adjacent structures such as the posterior thalamus or corpus callosum, suggesting a more invasive nature. T2-weighted images revealed nonspecific high signal lesions in all five cases.

Treatment of rat experimental brain tumors by herpes simplex virus thymidine kinase gene-transduced allogeneic tumor cells and ganciclovir

Transfer of the herpes simplex virus thymidine kinase (HSVtk) gene, followed by administration of ganciclovir (GCV), generates the "bystander effect," in which HSVtk-negative wild-type cells are killed by GCV, as are HSVtk-expressing cells. Our previous study demonstrated that intracranial 9L gliomas could be efficiently treated due to this bystander effect by injecting the 9L glioma cells transduced with the HSVtk gene in the vicinity of the preimplanted wild-type 9L glioma and then administering GCV. For a possible clinical application of the bystander effect-mediated cell killing, we tested HSVtkgene-transduced allogeneic C6 glioma cells (C6tk) instead of syngeneic 9L glioma cells transduced with the HSVtk gene. Fisher rats were implanted intracranially with wild-type 9L glioma cells, subsequently injected with C6tk cells at the same brain coordinate, and thereafter treated with GCV or saline. When the rats were treated with GCV, a significant retardation of tumor growth was observed by serial magnetic resonance imaging, although this growth retardation was less prominent than that observed with 9L glioma cells transduced with the HSVtk gene; consequently, survival was prolonged (P < .01). Tumors that received C6tk cells contained almost no HSVtk-positive cells after treatment with GCV. Rejection of allogeneic tumor cells, although possibly incomplete in the brain, can also contribute to the safety of this therapeutic strategy.

Recurrence of sellar and suprasellar tumors in children treated with hGH--relation to immunohistochemical study on GH receptor

PURPOSE

GH replacement therapy is required in the majority of children with GH deficiency after treatment of sellar and suprasellar tumors. Owing to the high cell proliferative ability of human GH (hGH), its influence on tumor recurrence has been debated. We retrospectively studied the immunohistochemical expression of the GH receptor in various tumor tissues, in order to investigate the relation between tumor recurrence and hGH replacement.

METHODS

GH replacement therapy was performed in 25 patients (8 boys and 17 girls) after the treatment. Tumor recurrence was noted in 4 patients (craniopharyngioma: 2 patients, pilocytic astrocytoma and germinoma: 1 each). Immunohistochemical study of GH receptor in tumor tissue was carried out in those recurrent and recurrence-free cases, by using MAb 263 as a primary antibody.

RESULTS

Two patients with recurrent craniopharyngioma were positive for MAb 263, but 1 recurrence-free patient was negative. Patients with pilocytic astrocytoma (recurrent and recurrence-free: 1 each) were all positive. Five patients with germinoma (1 with recurrence and 4 without recurrence) were all negative.

CONCLUSION

In the patients with craniopharyngioma treated with GH, a positive immunohistochemical expression of GH receptor in tumor tissue may indicate a high probability of recurrence. In our cases, GH receptor was positive in astrocytomas and negative in germinomas, with or without recurrence. It is therefore speculated that each brain tumor may have its specificity in GH receptor expression.

Significance of surgical resection for the treatment of multiple brain metastases

BACKGROUND

We investigated the role of surgery in the treatment of multiple brain metastases when performed with radiation therapy.

PATIENTS AND METHODS

One hundred and thirty-eight patients who underwent resection for brain metastases and received 30 Gy or more of adjuvant radiation therapy were entered into this study. Seventy-seven of the 138 patients (56%) had single brain metastases (Single Group), while the remaining 61 patients (44%) had multiple foci (Multiple Group). The 138 patients were divided into four subgroups; patients in Single Group treated with total or subtotal resection (Group A), those in Multiple Group who underwent total or subtotal resection and had remaining tumors smaller than 2 cm (Group B), those in Single Group treated with partial resection (Group C), and the other patients in Multiple Group (Group D).

RESULTS

The median survival was 8.7 and 9.2 months for the Single Group and the Multiple Group, respectively (not statistically different). The median survival was 9.6, 12.4, 3.7, and 4.5 months for Groups A, B, C, and D, respectively. Survival duration differed significantly between Groups A/B and Groups C/D (p < 0.05).

CONCLUSIONS

Surgical reduction of tumor volume which is approximately larger than 2 cm improves the efficacy of adjuvant radiation therapy and contributes to survival even in the patients with multiple brain metastases.

Homozygous deletion of the p16/MTS-1/CDKN2 gene in malignant gliomas is infrequent among Japanese patients

We have analyzed the status of the p16/MST-1/CDKN2 gene in 63 brain tumors from Japanese patients. With quantitative multiplex polymerase chain reaction (PCR) assay using the exon 2 primers of the p16 gene and control chromosome 9qSTS primers, we found homozygous deletion of the p16 gene in 7 cases; in 1 out of 10 cases of anaplastic astrocytomas (WHO grade III), 6 out of 35 cases of glioblastoma multiformes (grade IV) but in none of the tumors of grade I or II. We also found mobility-shifted PCR products in 8 cases using the single-strand conformation polymorphism technique. DNA sequencing of the aberrantly migrated products revealed that 5 cases of glioblastoma multiforme had mutations which caused amino acid substitutions. We found one case with silent mutations and two cases with nucleotide changes in the non-coding region. The frequency of the alteration of the p16 gene, either homozygous deletion or mutation accompanied with amino acid substitutions, increased in malignant brain tumors (grade III and IV) compared with that in low grade tumors (grade I and II) (p=0.0275), suggesting possible role(s) of the gene in the progression of brain tumors. In addition, the low frequency of homozygous deletions shown in this study is quite different from previous reports that demonstrated frequently deleted p16 gene in malignant gliomas from Caucasian patients. We have also shown the presence of heterogeneous cell populations within the glioblastoma masses based on the variety of the mutated p16 sequences. The present study, therefore, suggests a possible racial difference in the mechanism of the tumorigenesis and a heterogeneity of malignant gliomas developed during the tumor progression.

Isolated metastases of adenocarcinoma in the bilateral internal auditory meatuses mimicking neurofibromatosis type 2--case report

A 56-year-old male with a history of lung cancer presented with isolated metastases of adenocarcinoma in the bilateral internal auditory meatuses (IAMs), mimicking the bilateral acoustic schwannomas of neurofibromatosis type 2, and manifesting as rapidly worsening tinnitus and bilateral hearing loss. Magnetic resonance imaging showed small tumors in both IAMs with no sign of leptomeningeal metastasis. The preoperative diagnosis was neurofibromatosis type 2. Both tumors were removed and the histological diagnoses were adenocarcinoma. Neuroimaging differentiation of a solitary metastatic IAM tumor from a benign tumor is difficult, although rapidly progressive eighth cranial nerve dysfunction suggests a malignant process. Metastases should be considered as a rare diagnostic possibility in a patient with small tumors in both IAMs.

Glucose and methionine uptake and proliferative activity in meningiomas

Despite similar benign histological appearances, proliferative activity of meningiomas varies tumor to tumor, and even region to region in a tumor. To predict proliferative potential before surgery, we compared regional uptake of 2-[18F]fluoro-2-deoxyglucose ([18F]FDG) and L-[methyl-11C]methionine ([11C]MET) with histological indices of tumor proliferative activity in 17 specimens from six patients with meningioma obtained by PET guided stereotactic biopsies. Uptake of [11C]MET, an index of protein synthesis rate, significantly correlated not only with the count of nucleolar organizer regions (NORs), a histological index of protein synthesis, but also with Ki-67 index, a histological index of proliferative activity. On the other hand, [18F]FDG uptake showed no significant correlation with Ki-67 index or clinical malignancy. These results suggest that [11C]MET-PET is a useful tool for predicting tumor proliferative potential in meningiomas.

Paraganglioma in the frontal skull base--case report

A 56-year-old female presented with a paraganglioma in the left anterior cranial fossa who manifesting as persistent headache. Computed tomography and magnetic resonance imaging showed a solid, enhanced tumor with a cystic component located medially. The tumor was attached to the left frontal base and the sphenoid ridge. Angiography demonstrated a hypervascular tumor fed mainly by the left middle meningeal artery at the left sphenoid ridge. The preoperative diagnosis was meningioma of the left frontal base. The tumor was totally resected via a left frontotemporal craniotomy. Histological examination revealed the characteristic cellular arrangement of paraganglioma generally designated as the "Zellbaren pattern" on light microscopy. Only 10 patients with supratentorial paraganglioma have been reported, seven located in the parasellar area. The origin of the present tumor may have been the paraganglionic cells which strayed along the middle meningeal artery at differentiation.

Glucose and methionine uptake by rat brain tumor treated with prodrug-activated gene therapy

The effect of acyclovir (ACV) on the metabolism of rat 9L-gliosarcoma cells expressing the herpes simplex virus-thymidine kinase gene was studied using 2-deoxy-2-[18F]fluoro-D-glucose (FDG) and L-[methyl-11C]methionine. Though the average weight of the tumors treated with ACV was significantly lower than that of the saline-injected control group, FDG and methionine uptake per weight of tumor tissue was not different between the two groups. This result exhibits a striking contrast to the metabolic pattern observed after radiation therapy, suggesting the different pathways regarding tumor cell death between the therapies.

Mutation of the p53 gene in human astrocytic tumours correlates with increased resistance to DNA-damaging agents but not to anti-microtubule anti-cancer agents

Astrocytic tumours often become resistant to a variety of chemotherapeutic agents in advanced stages and frequently possess mutations in the p53 tumour-suppressor gene. Previous studies using established cell lines to investigate the relation between mutated p53 genes and altered resistance to anti-cancer agents brought inconsistent results. In this report, we examined the status of the p53 gene in 56 astrocytic tumour specimens by single-strand conformation polymorphism and their in vitro chemosensitivity to 30 different kinds of anti-cancer agents. The chemosensitivity was determined by drug-induced cell death using flow cytometry. We found that the mutated p53 gene correlated with increased resistance to DNA-damaging agents but the sensitivity to anti-microtubule agents was independent of the mutation, suggesting a clinical significance of the status of p53 gene in astrocytic tumours and a rational application of anti-microtubule agents to the patients with p53-mutated astrocytic tumours.

Bystander effect-mediated therapy of experimental brain tumor by genetically engineered tumor cells

Transfer of the herpes simplex virus-thymidine kinase (HSV-tk) gene, followed by administration of ganciclovir (GCV), generates the "bystander effect," in which HSV-tk-negative wild-type cells, as well as HSV-tk-expressing cells, are killed by GCV. To eradicate an intracranial tumor by this bystander effect, we injected the tumor cells transduced with the HSV-tk gene (TK cells) in the vicinity of the preimplanted wild-type tumor and then administered GCV. Wild-type 9L-gliosarcoma cells (1 x 10[5]) were implanted into the brain of syngeneic Fisher rats. On the next day, rats were injected with TK cells (1 x 10(5) or 3 x 10[5]) or medium alone at the same brain coordinate and then treated with GCV or saline. Administration of GCV significantly prolonged the survival of the rats injected with TK cells compared with that injected with medium alone (p < 0.01). Reduction in tumor size and retardation of tumor growth were observed by serial magnetic resonance imaging in the rats that received the combination of TK cells and GCV. The results show that the bystander effect is also achieved in vivo even when TK cells and wild-type cells are not simultaneously implanted. This treatment modality circumvents potential risks accompanied with in vivo gene transfer. Because there remained substantially no HSV-tk-positive cells in the recurrent tumors, this modality offers a "safe" therapeutic strategy against human malignant gliomas.

Induction of acquired immunity in rats that have eliminated intracranial gliosarcoma cells by the expression of herpes simplex virus-thymidine kinase gene and ganciclovir administration

We examined a possible antitumor response against 9L rat gliosarcoma cells induced by the expression of the herpes simplex virus-thymidine kinase (HSV-TK) gene and the ganciclovir (GCV) system. Based on the amount of the major histocompatibility complex (MHC) class I antigens expressed on 9L cells transduced by the HSV-TK gene (9L/HSV-TK) we selected two clones (clones H and L), which represent high and low expressors of class I antigens, respectively. By means of serial magnetic resonance imaging we followed the change of tumor volumes of each clone in syngeneic rats, and found that the intracranial tumor growth was inversely correlated with the expression of MHC class I antigens, although in vitro growths of the clones remained unchanged. Moreover, histological examination revealed significant lymphocyte infiltration in the 9L/HSV-TK tumor of high MHC expression but not in the wild-type tumor. The therapeutic effect of GCV on them was not different, but we observed a prolonged survival of the rats which had eliminated 9L/HSV-TK clone L tumors by the treatment of GCV and were rechallenged with the same cells compared with the survival of naive rats inoculated with clone L cells. These data collectively suggest that the immune response operates even in the brain previously described as an immunologically privileged site.

Prediction of drug cytotoxicity in 9L rat brain tumor by using flow cytometry with a deoxyribonucleic acid-binding dye

OBJECTIVE

Flow cytometry (FCM) with a deoxyribonucleic acid (DNA)-binding dye, propidium iodide, provides a rapid and quantitative method to detect apoptotic cell death. This technique was used to examine the sensitivity of tumor cells to anticancer agents, as a novel test of chemosensitivity in vitro.

METHODS

The in vitro chemosensitivity of 9L gliosarcoma cells to a panel of anticancer agents (cisplatin, nimustine, adriamycin, cyclophosphamide, vincristine, 5-fluorouracil, and methotrexate) was investigated by both FCM, yielding DNA histograms, and a microtiter tetrazolium test, measuring cellular metabolism. Clinically achievable concentrations of the agents were used for the analysis of DNA histograms and proliferation of 9L cells in vitro. Rats intracranially inoculated with 9L cells were treated with the agents, and tumor masses were visually monitored by using magnetic resonance imaging with gadolinium-diethylenetriaminepentaacetic acid enhancement.

RESULTS

The cytotoxic effect of anticancer agents examined by the microtiter tetrazolium test correlated with a decreased G0/G1 peak in the DNA histograms. Serial FCM analysis showed that the decrease in the G0/G1 peak was subsequently accompanied by increased hypodiploid areas, suggesting DNA fragmentation induced by the agents. The in vitro chemosensitivity test and cell proliferation examination showed that all agents except cisplatin were effective. Growth retardation of inoculated brain tumors and prolonged survival of inoculated rats were observed with treatment with the anticancer agents, except cisplatin.

CONCLUSION

The present study shows that FCM analysis with a DNA-binding dye can detect DNA damage induced by anticancer agents, and it suggests that this technique is a novel method to test chemosensitivity in vitro.

Evaluation of the bystander effect in experimental brain tumors bearing herpes simplex virus-thymidine kinase gene by serial magnetic resonance imaging

Antitumor effects of herpes simplex virus-thymidine kinase (HSV-tk) gene transfer followed by ganciclovir (GCV) administration were studied by serial magnetic resonance imaging (MRI) with reference to the bystander effect. Mixed populations of 9L-gliosarcoma cells transduced with the HSV-tk gene (TK cells) and wild-type 9L cells were implanted into the brain of syngeneic Fisher rats at various ratios (total cell number, 10(5) cells; percentage of TK cells, 100%, 25%, 10%, or 0%). Rats were treated with GCV (30 mg/kg per day) or saline for 14 days and tumor masses were visually monitored using MRI. All of the saline-treated rats (regardless of TK cell percentage) and GCV-treated rats inoculated with 0% TK cells died between day 19 and day 31 (mean survival, 22.9 days) due to progressive tumor growth. The GCV-treated rats inoculated with more than 10% of TK cells lived significantly longer than the saline-treated rats (p < 0.01). The mean survivals of GCV-treated groups were 50.7, 70.0, and longer than 100 days for 10%, 25%, and 100% TK cells, respectively. MRI study revealed that reduction in tumor size and disappearance of tumor were observed in the GCV-treated rats inoculated with 10% or 25% TK cells. Complete regression of the tumor was, however, observed only in the rats implanted with 100% TK cells. The present results show that the bystander effect is clearly observed in vivo in a TK percentage-dependent manner, and a population of more than 25% of TK-positive cells is required for complete tumor elimination.

In vivo bystander effect in the intracranial model with rat glioma cells reflects the clonal difference of HSV-TK positive cells

We have investigated clonal variations on the in vivo bystander effect of herpes simplex virus-thymidine kinase (HSV-TK)/ganciclovir (GCV) system, using an intracranial tumor model with 9L rat gliosarcoma cells. For this purpose, we established three 9L clones transduced with HSV-TK gene (9L-TK), each of which had similar TK activity but showed different tumor growth rate in vivo. The use of GCV in vitro confirmed previous reports that the bystander effect was manifest in a confluent culture condition, but not in a low cell density condition. In contrast, the therapeutic benefit of the in vivo bystander effect varied among each 9L-TK clone, and had a positive correlation with the in vivo growth rate of the clone. Thus, the bystander effect seems to reflect the growth rate of TK-positive cells, and these data raise a crucial point for applying the bystander effect to clinical trials.

The effect of steroid on thallium-201 uptake by malignant gliomas

In order to assess the effect of steroid on thallium-201 uptake by glioma, 201Tl single-photon emission tomography was performed before and after steroid administration in four patients with recurrent malignant glioma. After steroid administration the 201Tl index, expressed as the ratio of 201Tl uptake in the tumour to that in the contralateral cerebral hemisphere, was 0.77+/-0.11 of the value before steroid (mean+/-SD: P<0.05 by paired t test). The 201Tl index has been used as a possible indicator for the differentiation of malignant gliomas from relatively benign tumours or radiation necrosis. The present results indicate that the effect of steroid has to be taken into account when semi-quantitative analysis, e.g. by means of the 201Tl index, is used in patients with brain tumours.

Association of p53 gene mutation with decreased chemosensitivity in human malignant gliomas

Loss of p53 function is involved in tumorigenesis of various human cancers, but the relation between mutation of the p53 tumor-suppressor gene and the chemo- and radiosensitivity of tumors remains unclear. Mutated p53 gene in malignant glioma is often associated with progression and recurrence of malignancy, and these events are closely linked with increased resistance to both chemotherapy and radiation. We have examined the status of the p53 gene in malignant gliomas obtained from 34 patients (glioblastoma: 29 cases, anaplastic astrocytomas: 5 cases). The chemosensitivities of these specimens using 28 kinds of anti-cancer agents were determined using an in vitro assay system. Overall, 12 mutated cases of p53 gene were found in malignant glioma samples. The mean numbers of effective agents were 0.58 for the tumor samples with p53 mutations and 5.00 for tumors without mutations. Our data indicate that p53 gene mutation predisposes to decreased cell killing via chemotherapy in malignant gliomas.

Quantifying brain tumor blood flow by the microsphere model with N-isopropyl-p-[123I]iodoamphetamine super-early SPECT

Regional cerebral blood flow was quantitatively measured in 6 patients with brain tumor by the microsphere model with N-isopropyl-p-[123I]iodoamphetamine (IMP) "super-early" single photon emission computed tomography (SPECT) images obtained 4-6 min after IMP injection with a three-head rotating gamma camera. The ratio of radioactivities (counts/pixel/min) in the "early" SPECT images (taken 25-55 min after IMP injection) to the "super-early" images of the brain tumors was 1.47 +/- 0.13 (mean +/- SD, n = 6), which was significantly lower than the ratio in the normal cerebral cortices (1.93 +/- 0.25) (p < 0.01). This indicates faster clearance of IMP from the tumor tissue than that from the normal brain tissue. Blood flow values for the brain tumors obtained by the microsphere model based on the "super-early" SPECT images were 39.3 +/- 12.4 ml/100 g/ min, which was similar to the blood flow values for normal gray matter and in agreement with previous studies with positron emission tomography.

Improved preparation and swimming behavior of Triton-extracted models of Didinium nasutum

An improved method for the preparation of Triton X-100 extracted models of Didinium nasutum was established. Didinium models prepared by treatment with a Triton X-100 solution, containing specific proteolysis inhibitors and dimethyl sulfoxide, maintained an intact shape at 25 degrees C for a longer time than models prepared by treatment with a Triton X-100 solution not containing the proteolysis inhibitors and dimethyl sulfoxide. The improved Didinium models were reactivated so as to swim forward in the presence of Mg2+ and ATP or ADP. They did not swim backward in response to Ca2+, in contrast to well-known Paramecium models. However, the improved Didinium models showed circular swimming and spinning in response to 10(-6) M or higher concentrations of Ca2+. This observation suggests that the quick directional change as well as the spinning, which are characteristic of live Didinium, are due to an increase in the endoplasmic Ca2+ concentration around the ciliary system. The response of the Didinium ciliary system to Ca2+ may differ from the response of the Paramecium ciliary system to Ca2+.

Intra-arterial ACNU and cisplatin chemotherapy for the treatment of glioblastoma multiforme

Intra-arterial (IA) chemotherapy has achieved no obvious clinical superiority as a treatment for glioblastoma multiforme despite the many theoretical advantages. The clinical courses of 38 patients who underwent surgery and radiotherapy with IA 1-(4-amino-2-methyl-5-pyrimidinyl)-methyl-3-(2-chloroethyl)-3-nitrosourea hydrochloride (ACNU) and cisplatin were reviewed. Tumor regrowth was evaluated by comparison of contrast-enhanced areas on computed tomographic scans. The initial response rate was 19 of 32 patients evaluated, and the median survival time (MST) for all 38 patients was 53 weeks. Local recurrence was observed in 20 patients, and distant recurrence (areas more than 3 cm from the original tumor margin) was observed in 15 patients. The MST was 59 weeks for patients without distant recurrence, and 42 weeks for patients with distant recurrence (statistically not significant). Adjuvant IA ACNU and cisplatin chemotherapy did not improve the survival time. An important clinical feature was the high incidence of distant recurrence, in contrast to experience with other conventional therapy regimens. Distant recurrence, without extended survival, may suggest insufficient control of tumor regrowth.

Assessment of the brain areas perfused by superselective intra-arterial chemotherapy using single photon emission computed tomography with technetium-99m-hexamethyl-propyleneamine oxime--technical note

The brain areas perfused by superselective intra-arterial (i.a.) chemotherapy were assessed using single photon emission computed tomography (SPECT) with technetium-99m-hexamethyl-propyleneamine oxime (99mTc-HMPAO). A superselective catheter was introduced into the anterior, middle, or posterior cerebral artery of patients with malignant glioma for i.a. chemotherapy. 99mTc-HMPAO was subsequently injected via the same catheter used for chemotherapy, and a higher dose of 99mTc-HMPAO was injected intravenously to obtain adequate background brain images. Comparison of the SPECT images with magnetic resonance images could confirm complete perfusion of the tumor tissue. In two patients with malignant glioma, regions of interest were selected in the peritumoral brain area and a reference brain area, and the radioactivity was measured. The concentration of 99mTc-HMPAO was about 50 times higher in tissue perfused by superselective injection into anterior or middle cerebral artery compared to intravenous injection. 99mTc-HMPAO SPECT is readily available in many institutions and the information provided is useful for planning more effective and safe i.a. chemotherapy.

[Intra-arterial ACNU, CDDP chemotherapy for brain metastases from lung cancer: comparison of cases with and without intra-arterial mannitol infusion]

To assess whether therapeutic efficacy is related to intra-arterial (IA) mannitol infusion prior to ACNU and cisplatin (CDDP) for brain metastases from lung cancer, clinical results of patients with and without IA mannitol infusion were compared. Thirty-nine patients were randomly assigned to either a mannitol infusion group (group A) or a non-mannitol infusion group (group B). There were 22 patients in group A and 17 in group B. During radiotherapy, ACNU and CDDP, at a dose of 100 mg/body, were given through the common carotid artery at a rate of 20 mg/min. In group A, 50 ml of 20% mannitol was injected intra-arterially at a rate of 50 ml/min immediately prior to the injection of chemotherapeutic agents. Major complications, such as seizure and neurotoxicity, were not observed. Complete response (disappearance of enhanced tumor mass) was obtained in 72% of group A and in 67% of group B. The median time to tumor progression was 40 weeks for group A and 22 weeks for group B. The median survival time (MST) was 45 weeks for group A and 30 weeks for group B. The survival time was significantly longer in group A as compared to group B (p < 0.05). When the patients who died of failure of vital organ systems other than brain complications were excluded in calculating the survival time, the MST was 69 weeks for 11 patients of group A and 34 weeks for 7 patients of group B. These data suggest that an effort to increase drug delivery to the brain tumor may indeed lengthen the survival time of patients with brain metastases from lung cancer.

Intra-arterial mannitol infusion in the chemotherapy for malignant brain tumors

To assess whether therapeutic efficacy is related to the intra-arterial (IA) mannitol infusion prior to ACNU and cisplatin (CDDP) for malignant brain tumors, the survival time of patients with and without mannitol infusion was compared. Ninety-eight patients were randomly assigned to either a mannitol infusion group (group A) or a non-mannitol infusion group (group B); 34 with malignant gliomas (18 in group A and 16 in group B) and 64 with brain metastases (36 in group A and 28 in group B). During radiotherapy, ACNU and CDDP at a dose of 100 mg/body were given through the common carotid artery at a rate of 20 mg/min. In group A, 50 ml of 20% mannitol was injected intra-arterially at a rate of 50 ml/min immediately prior to the injection of chemotherapeutic agents. Of the patients with malignant gliomas, the median survival time (MST) was 52 weeks for all 34 cases, 68 weeks for group A, and 47 weeks for group B. Survival analysis showed no significant differences between the two treatment groups. Of the patients with brain metastases, the MST was 40 weeks for all 64 cases, 47 weeks for group A, and 24 weeks for group B; the survival time was significantly longer in group A as compared to group B (p < 0.05). This study has demonstrated that, for the patients with brain metastases, IA mannitol infusion provided a survival benefit in the IA chemotherapy employing ACNU and CDDP. In contrast, IA mannitol infusion offered no survival benefit to the patients with malignant gliomas.

[Evaluation of CT-guided stereotactic hematoma aspiration in mild cases with putaminal hemorrhage]

Reported here is the effectiveness of surgical management in mild cases with putaminal hemorrhage (neurological grading 1 or 2, described by Kanaya, et al.). Ten cases were treated by CT-guided stereotactic hematoma aspiration (aspiration group), and another 10 cases were treated by only medical therapy (conservative group). The mean interval from the onset to operation was 7.2 days. In both groups, serial change in the motor function of the upper extremity was examined and the neuropsychological function was also evaluated at 2 weeks after onset. Perifocal low-density area around the hematoma was estimated on CT scan at 2 weeks after onset. Mean hemispheric cerebral blood flow (mCBF) was measured at 5-days, 2 weeks and 6 months after onset, respectively in each group. The activity of daily life (ADL) was evaluated at 6 months after onset. There was no statistically significant difference in age, neurological grading and CT findings on admission between the 2 groups. At 2 weeks after onset, no case had deteriorated in motor function in the aspiration group. On the other hand, 2 cases had deteriorated in the conservative group. The neuropsychological function was considerably improved in the majority of cases in the aspiration group. Perifocal low area was significantly narrow on CT scan in the aspiration group. At 2 weeks after onset, the mCBF of the affected side was 53.8 +/- 6.0 ml/100g/min in the aspiration group, whereas it was 42.0 +/- 5.7 ml/100g/min in the conservative group. This difference was statistically significant.(ABSTRACT TRUNCATED AT 250 WORDS)

[Computed tomography in diagnosis of diffuse axonal injury]

Diffuse axonal injury (DAI) has been described in instances of prolonged traumatic coma on the basis of the neuropathological findings, but the same findings are also found in patients with cerebral concussion. Experimental studies confirm that the quality of survivors following trauma is directly proportional to the amount of primarily injured-axon. When the injured axon lies in a widespread area of the brain, outcome for the patient is always poor. In a series of 260 severely head-injured patients, based on their poor outcome, 69 (27%) were diagnosed as DAI. Because of their relatively good outcome, eighty-two patients (32%) were classified into non-DAI group. The predominant CT finding of DAI patients was intraparenchymal deep-seated hemorrhagic lesion. This was observed in 28 patients (41%). Normal CT was also observed in 11 patients (16%). On the other hand, 8 of the non-DAI group (10%) manifested deep-seated lesions. Diffuse cerebral swelling (DCS) appeared in both groups in the same incidence. Subarachnoid hematoma in the perimesencephalic cistern (SAH (PMC] and intraventricular hematoma (IVH) were observed in 64% of the DAI group, and in 23% of the non-DAI group. The available evidence indicates that various types of hematoma seen in the deep-seated structures of the brain do not have an absolute diagnostic value, but the frequency of hematoma is thought to increase in proportion to the amount of injured-axon.

Post-traumatic intention tremor--clinical features and CT findings

Eight patients with post-traumatic intention tremor were reported. Intention tremor developed in the young as a late complication of severe head injury (Glasgow Coma Scale was below 8 in all cases) and impaired their functional outcome. This state was treatable with medication or by stereotactic thalamotomy. Neurologically, all the patients lapsed into coma immediately after the injury and many patients manifested clinical signs of a midbrain lesion in the chronic stage. The characteristic CT (computed tomography) findings in the acute stage were a high density area in the midbrain, accompanied by diffuse cerebral swelling or intraventricular hemorrhage, and in the chronic stage, brain atrophy or ventricular enlargement were the most prominent CT findings. These characteristics, indicating diffuse brain damage in addition to midbrain injury, may suggest the presence of shearing injury. The midbrain damage is consistent with the classical hypothesis that the damage to the Dentate-Rubro-thalamic system accounts for the occurrence of intention tremor. Furthermore, the presence of diffuse brain damage suggests that a more widespread brain injury may participate in its development.

[Single burr hole irrigation without drainage in chronic subdural hematoma]

The surgical treatment of chronic subdural hematoma has evolved from membranectomy through craniotomy to burr hole irrigation. The latter approach is based on utilization of the natural absorptive process that is thought to be part of the life cycle of the hematoma. To test this theory, the authors treated fifty-nine patients with chronic subdural hematoma according to the following protocol. Local anesthesia was induced with a modified neuroleptanalgesic procedure. A single burr hole was drilled, usually in the posterior frontal region, and irrigation was carried out until the washing was clear. Subdural drainage was not employed. Patients were permitted to walk about on the following day. The outcome was better than that achieved with conventional treatment. Such complications as tension pneumocephalus and intracranial hematoma were not observed, and only one patient (1.7%) had a recurrence. The results of this study indicate that single burr hole irrigation without drainage is a very simple and effective treatment for chronic subdural hematoma. The absence of subdural drainage may be an important feature, since drainage may contribute to the development of certain postoperative complications. Also, the simplified procedure allows patients early mobility, which may be of particular benefit to the elderly.