Simultaneous XIAP and cIAP1/2 inhibition by a dimeric SMAC mimetic AZD5582 induces apoptosis in multiple myeloma

Overexpression of inhibitor of apoptosis (IAP) proteins is associated with poor prognosis. In multiple myeloma (MM), the IAP inhibitors (IAPi), LCL161, have been evaluated in preclinical and clinical settings but are not fully effective. Among IAPs, XIAP has the strongest anti-apoptotic function with direct binding activity to caspases and cIAP1 and cIAP2 are positive regulator of NF-κB signaling. Prior IAPi such as LCL161 has high affinity to cIAP1 and cIAP2 resulting in inferior inhibiting activity against XIAP. A novel dimeric IAPi, AZD5582 (C58H78N8O8), have high binding potency to XIAP with EC50 dose of 15 nM, enabling to simultaneous inhibit XIAP and cIAP1/2. AZD5582 monotherapy showed cell growth inhibition for all MM cell lines, MM1S, RPMI8226, U266 and KMS-5 and induced apoptosis. AZD5582 further showed anti-proliferation effect under the IL-6 additional condition and inhibited JAK-STAT signaling triggered by IL-6. AZD5582 combined with carfilzomib therapy showed a synergistic effect. Enhanced apoptosis was also observed in combination therapy. Synergistic effect was further observed with other conventional therapeutics. Simultaneous XIAP and cIAP1/2 inhibition by the dimeric IAPi AZD5582 is promising. This study provides a rationale of AZD5582 as a new treatment strategy in monotherapy and in combination therapy.

Combination of psoas muscle mass index and neutrophil/lymphocyte ratio as a prognostic predictor for patients undergoing nonsurgical hepatocellular carcinoma therapy

Background and Aim

Reliable predictors for hepatocellular carcinoma (HCC) are urgently needed. The psoas muscle index (PMI) is a simple and rapid method for evaluating muscle atrophy. Furthermore, the neutrophil/lymphocyte ratio (NLR) is a prognostic factor that is easy to calculate in everyday clinical practice. We aimed to investigate the value of the PMI and NLR as prognostic factors for patients receiving nonsurgical HCC therapy, hepatic arterial infusion chemotherapy (HAIC), transcatheter arterial chemoembolization (TACE), or molecular targeted drugs such as sorafenib (SOR) and lenvatinib (LEN).

Methods

We enrolled 87 patients with HCC who were treated with HAIC, TACE, SOR, or LEN. The primary endpoint was overall survival (OS) with variable PMI or NLR status. For Barcelona Clinic Liver Cancer (BCLC)‐B patients, useful prognostic factors were examined by comparing the OS between stratified groups. Prognostic factors including PMI and NLR were evaluated by univariate and multivariate analysis.

Results

Analysis of HAIC or TACE (HAIC/TACE) and SOR or LEN (SOR/LEN) patients showed significant differences in OS between low and high PMI. In patients treated with TACE, there was a significant difference in OS between low and high NLR. For BCLC‐B and low PMI, the prognosis was significantly worse for SOR/LEN than for TACE, although there was no difference for high PMI, suggesting that PMI may be useful for treatment selection. In addition, the prognostic formula composed of PMI, NLR, and up‐to‐seven criteria developed in the present study may be useful.

Conclusion

PMI and NLR are considered to be independent prognostic factors for HCC.

[Treatment of POEMS syndrome with lenalidomide and dexamethasone]

We report three cases of POEMS syndrome treated with lenalidomide and dexamethasone who presented with peripheral neuropathy. All of them had markedly elevated serum vascular endothelial growth factor (VEGF) levels treated with lenalidomide and dexamethasone for severe peripheral neuropathy, which normalized serum VEGF levels and improved peripheral neuropathy. The standard treatment of POEMS syndrome has not been established, but has been effectively treated with high-dose chemotherapy with autologous stem cell transplantation. Newer agents currently used for plasma cell dyscrasias include bortezomib and immunomodulatory drugs, such as thalidomide and lenalidomide. A randomized controlled trial on thalidomide plus dexamethasone for POEMS syndrome showed reduced serum VEGF levels after therapy; however, the incidence of peripheral neuropathy, a well-known side effect of both thalidomide and bortezomib, increased. Lenalidomide is associated with lower incidence of peripheral neuropathy compared to thalidomide and bortezomib, making it a reasonable treatment option for POEMS syndrome.

Abstract 2112: FoxO3a activation by HDAC class IIa inhibition induces cell cycle arrest in pancreatic cancer cells

Pancreatic cancer is highly chemo-resistant associated with oncogenic mutations such as KRAS and/or p53. The effect of conventional chemotherapy is not sufficient and new target and strategy is urgently needed.

The forkhead box (Fox) proteins are multidirectional transcriptional factors strongly implicated in malignancies. Although Fox O (FoxO) protein, and particularly FoxO3a, works as negative regulator of cell proliferation by repressing cyclin proteins and inducing cell cycle inhibitors such as p21Waf1/Cip1, its expression is consistently suppressed by several oncogenic pathways including phosphatidylinositol-3 kinase (PI3K) / AKT pathway, constitutively activated in pancreatic cancer. Thus, upregulating FoxO3a activity could be a promising target of pancreatic cancer treatment without impact of underlying oncogenic mutations.

Class IIa Histone deacetylase (HDAC) is a subgroup of HDAC. Though HDAC inhibitors (HDACi) have been extensively investigated as a cancer target, its action mechanism is considered due to histone modification by class I. Biological significance of class IIa HDACs which have minimal histone deacetylation activity have not been elucidated yet. Recent studies show class IIa HDACs act as a transcriptional regulator including FoxO3a. In this study, we investigate the biologic impact of HDAC class IIa inhibition on FoxO3a and anti-tumor effect against pancreatic cancer cell line using selective class IIa HDACi TMP269.

TMP269 treatment showed increased FoxO3a expression in a dose dependent manner with immunoblotting and modest cell growth inhibition effect at 57.5 μM of IC50 dose for 48-hour treatment against AsPC-1 in MTT. G1/S arrest was observed with cell cycle assay. Upregulated p21Waf1/Cip1 and downregulated CDK2 and 4/6 and cyclin D1 and D2 expressions were further observed, consistent with inducing G1/S arrest and transcriptionally activated FoxO3a. Importantly, upregulated p21Waf1/Cip1 was observed in AsPC-1 p53 null cell line, suggesting independent with p53 pathway. These findings suggest upregulated FoxO3a induced by HDAC class IIa inhibition activated its transcription and resulted in cell growth inhibition.

Because PI3K/AKT leads FoxO3a to the ubiquitylation-mediated proteasome degradation, we examined irreversible proteasome inhibitor carfilzomib (CFZ) combined with TMP269, aiming synergistic FoxO3a upregulating. As expected, FoxO3a expression was further increased in TMP269 combined with CFZ compared with TMP269 or CFZ alone. Following the activated FoxO3a, p21Waf1/Cip1 expression was upregulated and cell growth inhibition was dramatically enhanced.

In conclusion, HDAC class IIa inhibition modified FoxO3a transcriptional activation and upregulating FoxO3 by dual inhibition of HDAC class IIa and proteasome is promising target against pancreas cancer.

Citation Format: Makoto Usami, Shohei Kikuchi, Kohichi Takada, Yusuke Sugama, Yohei Arihara, Naotaka Hayasaka, Hajime Nakamura, Yuki Ikeda, Yusuke Kamihara, Masahiro Hirakawa, Makoto Yoshida, Masayoshi Kobune, Koji Miyanishi, Junji Kato. FoxO3a activation by HDAC class IIa inhibition induces cell cycle arrest in pancreatic cancer cells [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 2112. doi:10.1158/1538-7445.AM2017-2112

[Zoledronic Acid Administration is Effective for Hematopoiesis Management in a Patient with Primary Myelofibrosis]

An 80-year-old man received a diagnosis of anemia and a decreased platelet count from his physician in 2008, and was referred to our department where primary myelofibrosis was diagnosed.The patient was classified into the lower risk group according to the International Prognostic Scoring System(IPSS), and was followed up without treatment.In June 2010, pancytopenia progressed, and the patient was reclassified into the higher risk group.Blood count did not increase with metenolone treatment, but increased with zoledronic acid(ZA)that he started receiving from January 2012. After ZA treatment, circulating levels of vascular endothelial growth factor(VEGF)and transforming growth factor-b(TGF-b)decreased, and bone marrow biopsy showed an absence of reticular fibers and collagen fibers.In the present case, we observed that the blood count increased because of ZA-induced improvements in myelofibrosis.

[Efficacy of levocarnitine for tyrosine kinase inhibitor-induced painful muscle cramps in patients with chronic myelogenous leukemia]

Muscle cramps are side effects commonly associated with tyrosine kinase inhibitor (TKI) treatment. Patients suffering from muscle cramps are treated with various medications such as calcium, magnesium and vitamin supplements, but these therapies are often ineffective. We report two patients with chronic myelogenous leukemia who developed muscle cramps caused by TKI. These patients were treated successfully with levocarnitine. Both of our cases revealed the beneficial effects of levocarnitine treatment on TKI-induced muscle cramps.

Mast cells in diffuse large B-cell lymphoma; their role in fibrosis

AIMS

Mast cells (MCs) are associated with fibrosis in various diseases. MCs comprise two phenotypes: the MC(TC) phenotype contains tryptase and chymase, whereas the MC(T) phenotype contains tryptase. Interleukin (IL)-4 promotes the development of MC(TC) from the MC(T) phenotype. The aim of this study was to determine the relationship between MC phenotypes and fibrosis in diffuse large B-cell lymphoma (DLBCL).

METHODS AND RESULTS

We examined the distribution and density of MCs in 50 DLBCL and 20 reactive lymph nodes, and evaluated MC phenotypes and IL-4-expressing cells. To detect MCs, immunohistochemistry for tryptase and chymase was performed. The 50 DLBCLs were histologically divided into three groups: no fibrosis (32 cases), reticular type (eight cases) showing reticular fibrosis, and bundle type (10 cases) showing collagenous bundles. The density of tryptase-positive MCs was higher than that of chymase-positive MCs. The densities of tryptase-positive and chymase-positive MCs in fibrotic areas were significantly higher than those in the cellular areas in the reticular and bundle groups. Double immunostaining revealed that MCs in DLBCL comprised MC(T) and MC(TC) phenotypes. Chymase-positive MCs and T lymphocytes expressed IL-4. Although there were few chymase-positive MCs in reactive lymph nodes, the density of tryptase-positive MCs was not different from that in the 'no fibrosis' group.

CONCLUSIONS

Tryptase-positive and chymase-positive MCs are associated with fibrosis in DLBCL.

Oxidized Phosphatidylcholine in AlveolarMacrophages in Idiopathic Interstitial Pneumonias

It has been suggested that oxidative stress plays a pathogenic role in idiopathic interstitial pneumonias. Macrophage- or neutrophil-derived oxidants seem to be important sources of oxidative stress in this group of inflammatory disorders. Recent experimental studies have revealed that oxidative injury during inflammation or apoptosis can change phosphatidylcholine of cell membrane into its oxidized form, which serves as a ligand for macrophage scavenger receptor CD36. Recently, we developed a monoclonal antibody against oxidized phosphatidylcholine. Using this novel antibody, we performed an immunohistochemical investigation to clarify the localization of oxidized phosphatidylcholine in lung tissues of idiopathic interstitial pneumonias and a relationship between oxidized phosphatidylcholine localization and CD36 expression. Lung specimens obtained from patients with desquamative (n = 8) or usual interstitial pneumonia (n = 15) were studied. Thirteen normal lung tissues were also examined as controls. Antibodies against oxidized phosphatidylcholine, CD36, epithelial cells, macrophages, and neutrophils were used as primary antibodies. The positive cell number was counted by computer-aided morphometry. While there were no oxidized phosphatidylcholine-positive cells in normal lungs, lungs of desquamative or usual interstitial pneumonia contained large numbers of oxidized phosphatidylcholine-positive cells in the alveolar spaces. Double-staining analysis revealed that most oxidized phosphatidylcholine-positive cells were macrophages. The oxidized phosphatidylcholine-positive cells were increased in association with the increase in the densities of macrophages (Rs = 0.87, p < 0.0001) and neutrophils (Rs = 0.89, p < 0.0001). Accumulated macrophages also showed distinct CD36 expression. These findings suggest that oxidative stress and the related product, oxidized phosphatidylcholine, play an important role in the pathophysiology of idiopathic interstitial pneumonias.

[Meigs' syndrome associated with adenocarcinoma of the left fallopian tube]

A 52-year-old woman was admitted to the hospital with dyspnea on exertion and a feeling of abdominal fullness. Chest radiographs revealed a moderate bilateral pleural effusion. Examination of the effusion was in conclusive. Thoracoscopy and thoracic computed tomography (CT) failed to provide evidence pertaining to the etiology of the recurrent effusion. Elevation of serum CA-125 levels suggested the presence of an intrapelvic tumor, which was substantiated by pelvic CT. Laparotomy revealed a small amount of ascites. The resected specimen revealed a tumor of the left fallopian tube, which was histologically to be poorly differentiated adenocarcinoma. The pleural effusion disappeared after removal of the tumor and Meigs' syndrome was subsequently diagnosed. Primary fallopian tube adenocarcinoma is a rare cause of Meigs' syndrome.

[The management of chronic asthma with inhaled beta 2 agonists--regular use? symptomatic use?]

Beta-agonist is a widely used bronchodilator. Although it has an ability to dilate bronchus rapidly, it shows no or minimal relief for severe asthma and no effect on the inflammation which is thought as a most important factor in disease of asthma. Some reports showed that the regular use of inhaled beta 2 agonist induced hypersensitivity of bronchoconstriction, and some showed that the overdose of inhaled beta 2 agonist induced an increase of asthma death. We should discuss how we use inhaled beta 2 agonist systematically now. Depends on the several guidelines, inhaled beta 2 agonist can be used on demand for mild and moderate asthma, and if inhaled beta 2 agonist need to be used regularly for more severe condition of asthma, inhaled corticosteroid and anti-inflammatory agents should be started. Inhaled beta 2 agonist can be used up to 4 times a day. To save the dose of inhaled beta 2 agonist for the control of asthma, the use of a handy peak flow meter will be beneficial.

[A case of laryngeal and tracheobronchial tuberculosis]

The patient was 38-year-old male. His chief complaint was persistent cough. He had been diagnosed at an another clinic as tuberculosis by positive sputum culture. Laboratory findings at the first examination were as follows: ESR was 10 mm/1 hr and CRP was 0.920 mg/dl and other data were within normal limits. Chest X-ray showed infiltrative shadow in the left lower lobe. Bronchoscopic findings before treatment were as follows: there were ulcers on bilateral vocal cords, small white nodules with reddness in trachea and red nodules and white coated ulcers in left main bronchus. He was treated with combination chemotherapy (INH, RFP, EB) and the steroid inhalation was added 1 month later after the initiation of chemotherapy. Bronchoscopic findings at 2 months after starting chemotherapy were as follows: lesions of vocal cords and trachea were improved and lesion of left main bronchus was scarred without stenosis. Bronchial stenosis as sequelae of endobronchial tuberculosis deteriorates the patients' quality of life. Therefore it is important to diagnose endobronchial tuberculosis early and to start treat with chemotherapy as soon as possible, and the follow up by bronchoscopy should be done during treatment.

Elevation of tumour markers in serum and bronchoalveolar lavage fluid in pulmonary alveolar proteinosis

It is unclear whether tumour markers are generally increased in the serum and bronchoalveolar lavage fluid (BALF) of patients with pulmonary alveolar proteinosis (PAP). To clarify this point, levels of tumour markers were measured in the serum and BALF of patients with PAP. Squamous cell carcinoma (SCC) antigen, carcinoembryonic antigen (CEA), and carbohydrate antigens sialyl Lewis (CA 19-9) and sialyl SSEA-1 (SLX) were assayed with radioimmunoassay kits. Cytokeratin 19 fragments (CYFRA) were measured by enzyme-linked immunosorbent assay. Values for the tumour markers in serum, except for SCC, exceeded cut-off values in some PAP patients. Levels of the markers were higher in BALF compared with those in serum, and were significantly elevated in PAP patients compared with control subjects. There was a significant inverse correlation between CA19-9 level in BALF and arterial oxygen tension (PaO2) in PAP patients. A gradual elevation of CA19-9 and SLX was observed in a patient who showed a decrease in PaO2 level during the study period. In the light of these findings, it is possible that levels of tumour markers in BALF, especially levels of CA19-9 and SLX, may reflect the severity of the disease in PAP patients.

Elevation of tumour markers in serum and bronchoalveolar lavage fluid in pulmonary alveolar proteinosis

It is unclear whether tumour markers are generally increased in the serum and bronchoalveolar lavage fluid (BALF) of patients with pulmonary alveolar proteinosis (PAP). To clarify this point, levels of tumour markers were measured in the serum and BALF of patients with PAP. Squamous cell carcinoma (SCC) antigen, carcinoembryonic antigen (CEA), and carbohydrate antigens sialyl Lewis (CA 19-9) and sialyl SSEA-1 (SLX) were assayed with radioimmunoassay kits. Cytokeratin 19 fragments (CYFRA) were measured by enzyme-linked immunosorbent assay. Values for the tumour markers in serum, except for SCC, exceeded cut-off values in some PAP patients. Levels of the markers were higher in BALF compared with those in serum, and were significantly elevated in PAP patients compared with control subjects. There was a significant inverse correlation between CA19-9 level in BALF and arterial oxygen tension (PaO2) in PAP patients. A gradual elevation of CA19-9 and SLX was observed in a patient who showed a decrease in PaO2 level during the study period. In the light of these findings, it is possible that levels of tumour markers in BALF, especially levels of CA19-9 and SLX, may reflect the severity of the disease in PAP patients.

Clinical usefulness of CYFRA assay in diagnosing lung cancer: measurement of serum cytokeratin fragment

We evaluated the diagnostic usefulness of measurement of the soluble cytokeratin 19 fragment, a new tumor marker, in 391 patients with lung cancer and in 424 patients with benign lung diseases. Serum concentrations of cytokeratin 19 fragment were measured by a sandwich ELISA (CYFRA). The cut-off value was defined as 3.5 ng/ml, which is associated with a specificity of 85% for benign lung diseases. CYFRA had a high sensitivity (57.5%) in all subjects with lung carcinoma, and had a higher sensitivity for squamous cell carcinoma (73.1%, n = 141) than squamous cell carcinoma-related antigen (61.0%). CYFRA was associated with a relatively high sensitivity (42.1%) in early-stage squamous cell carcinoma (stage I, based on the classification of the Japan Lung Cancer Society), but the CYFRA titer was higher in advanced squamous cell carcinoma than in early-stage squamous cell carcinoma. Our findings suggest that CYFRA is potentially useful for diagnosis and monitoring of lung carcinoma, especially for squamous cell carcinoma.

Thrombin-induced expression of endothelial P-selectin and intercellular adhesion molecule-1: a mechanism for stabilizing neutrophil adhesion

Thrombin-induced expression of endothelial adhesivity toward neutrophils (PMN) was studied using human umbilical vein endothelial cells (HUVEC). HUVEC were challenged with human alpha-thrombin for varying durations up to 120 min, after which the cells were fixed with 1% paraformaldehyde and 51Cr-labeled human PMN were added to determine PMN adhesion. Endothelial adhesivity increased within 15 min after alpha-thrombin exposure, and the response persisted up to 120 min. Expression of endothelial adhesion proteins, P-selectin (GMP-140, PADGEM, CD62), and intercellular adhesion molecule-1 (ICAM-1; CD54) on the endothelial surface was quantitated by increase in the specific binding of anti-P-selectin mAb G1 and anti-ICAM-1 mAb RR1/1 labeled with 125I. P-selectin expression was maximal at 5-15 min alpha-thrombin exposure and decayed to basal levels within 90 min. In contrast, ICAM-1 activity increased at 30 min and remained elevated for 120 min after alpha-thrombin challenge. The initial endothelial adhesivity was dependent on P-selectin expression since PMN adhesion occurring within the first 30 min after alpha-thrombin challenge was inhibited by mAb G1. The later prolonged PMN adhesion was ICAM-1 dependent since this response was inhibited by mAb RR1/1 and to the same degree by the anti-CD18 mAb IB4. Anti-ELAM-1 mAb BB11 had no effect on adhesion of PMN to the alpha-thrombin-challenged cells. The initial P-selectin expression and PMN adhesion responses were reproduced by the 14-amino peptide (SFLLRNPNDKYEPF) (thrombin-receptor activity peptide; TRP-14) which comprised the NH2 terminus created by thrombin's proteolytic action on its receptors. However, TRP-14-induced PMN adhesion was transient, and TRP-14 did not cause ICAM-1 expression. The ICAM-1-dependent PMN adhesion mediated by alpha-thrombin was protein synthesis independent since ICAM-1 expression and PMN adhesion were not inhibited by cycloheximide pretreatment of HUVEC. Moreover, Northern blot analysis indicated absence of ICAM-1 mRNA signal up to 180 min after alpha-thrombin challenge. In conclusion, thrombin-induced endothelial adhesivity involves early- and late-phase responses. The initial reversible PMN adhesion is mediated by rapid P-selectin expression via TRP-14 generation. Thrombin-induced PMN adhesion is stabilized by a protein synthesis-independent upregulation of the constitutive ICAM-1 activity which enables the interaction of ICAM-1 with the CD18 beta 2 integrin on PMN.

Thrombin receptor 14-amino acid peptide mediates endothelial hyperadhesivity and neutrophil adhesion by P-selectin-dependent mechanism

Thrombin cleaves its receptor at arginine-41, resulting in the generation of a new receptor NH2-terminus with the sequence SFLLRNPNDKYEPF. This peptide (TRP-14) may signal a variety of thrombin's responses. We examined the effects of TRP-14 in inducing endothelial cell hyperadhesivity and neutrophil (PMN) adhesion to endothelial cell monolayers. Human umbilical vein endothelial cells (HUVECs) challenged with TRP-14 (10(-4) to 10(-5) M) produced concentration-dependent increases in endothelial adhesivity to PMN. In contrast, position 1 to 2 inverted peptide (FSLLRNPNDKYEPF) did not induce the response. The adhesion response was transient; that is, PMN adhesion increased within 15 minutes and decreased by 75 minutes after TRP-14 challenge of HUVECs. The transient endothelial adhesiveness paralleled the time course of P-selectin expression. TRP-14-induced release of P-selectin from intracellular stores may be a critical determinant of the response since treatment of endothelial cells with anti-P-selectin monoclonal antibody (mAb) G1 prevented the increase in PMN adhesion. Control nonneutralizing anti-P-selectin mAb S12 and mAb RR1/1 directed against intercellular adhesion molecule-1 (ICAM-1) on HUVECs were ineffective. The results indicate that the "tethered ligand" of the thrombin receptor created by the proteolytic action of thrombin on its receptor (i.e., TRP-14) signals increased endothelial adhesiveness by a P-selectin-dependent mechanism. Thrombin-induced PMN adhesion may involve formation of a new NH2-terminus of the endothelial thrombin receptor with the sequence SFLLRNPNDKYEPF followed by activation of endothelial second messenger pathways and the transient expression of P-selectin.

Ultrasonographic evaluation of neck and supraclavicular lymph nodes metastasized from lung cancer

The significance of ultrasonography in the evaluation of metastasized neck and supraclavicular lymph nodes from lung cancer was analyzed. By ultrasonography, the lymph nodes could be visualized clearly as low-echogenic round areas, and the size could be precisely measured in three dimensions. It was also possible to diagnose whether or not the lymph node adhered to the surrounding tissues and to determine the relationship and the connection of supraclavicular lymph node and upper mediastinal lymph node. The therapeutic effect related to the size of the lymph node was evaluable by ultrasonography. Therefore, the ultrasonographic approach to the neck and supraclavicular lymph nodes metastasized from lung cancer is considered to be useful for clinical use.

[A case of Sjögren's syndrome with a clinical course similar to diffuse panbronchiolitis]

A 64-year-old man was admitted because of some infection of the airway. Chest roentgenography showed a bilateral reticulonodular shadow which was similar to the shadow of DPB. Pathological findings obtained by lung biopsy indicated bronchiolitis. This case was diagnosed as Sjögren's syndrome because of the increase of titers of anti-ssA and anti-ssB antibody, lachrymal dysfunction, pathological findings and sialography. The relationship between DPB and lung lesions of Sjögren's syndrome was investigated.

[Analysis of peripheral lymphocyte subsets and changes due to erythromycin therapy in patients with diffuse panbronchiolitis]

It is well known that patients with diffuse panbronchiolitis (DPB) have various immunological abnormalities. The authors evaluated the peripheral lymphocyte subsets using two-color analysis by FACS. Convening percentages of activated CD3+, CD8+, and CD4+ cells in DPB patients, all, especially that of CD8+ cell, were greater in number before therapy compared to healthy controls. After erythromycin therapy, all three parameters decreased in all patients. Therapy with other antibiotics did not obtain any effects. These results suggested that patients with DPB had some immunological hyperreactivity and that erythromycin was effective in these patients by suppressing this activity. From these results, together with the fact that DPB is a type of sino-bronchial syndrome, the possible pathogenesis of DPB was thought to be related to some immunological defect and hyperreactivity in the respiratory system.

[A case of summer-type hypersensitivity pneumonitis with bronchoalveolar lavage performed 4 years before onset]

A 51-year-old man with chief complaints of cough, fever, and dyspnea was admitted to our hospital. Based on a home provocation test, transbronchial lung biopsy specimens, and a serum antibody, we diagnosed summer-type hypersensitivity pneumonitis. In 1983 when the patient was 46 years old, thymectomy was performed for thymoma. Prior to surgery, bronchoalveolar lavage (BAL) was performed. Total cell count and neutrophils had already increased in BALF. Furthermore, the increase in BALF cell neutrophil count was also seen at the time of admission and after the home provocation test. Because an increase of neutrophils in BALF cells was seen not only at onset but before onset, further studies are required to clarify the role of neutrophils and the factors that increase them in hypersensitivity pneumonitis.

[A case of necrotizing sarcoid granulomatosis diagnosed by open lung biopsy]

A 32-year-old female complained of productive cough and bloody sputum. Infiltrative shadows and cavitary lesions with thick and irregular wall in the bilateral lung fields and the swelling of mediastinal lymph nodes were pointed out on the chest radiography. Physical examination revealed no abnormal findings. ESR and the level of the serum angiotensin converting enzyme were slightly elevated. In the BAL (broncho-alveolar lavage) fluid, lymphocytes and neutrophils increased, and the OKT4/OKT8 ratio of the lymphocytes was 0.81. Open lung biopsy revealed numerous sarcoid granulomas with granulomatous vasculitis in the cavity wall, surrounding infiltrative lesions and hilar lymph nodes. After the administration of prednisolone, the infiltrative shadows and the cavitary lesions showed marked improvement. It was concluded that open lung biopsy is necessary for the diagnosis of NSG because the differential diagnosis between NSG and limited form of Wegener's granulomatosis is extremely difficult from such a small lung specimen as that obtained by trans-bronchial lung biopsy.

Ultrasonically guided needle biopsy in the diagnosis of mediastinal masses

The value of ultrasonic examination and ultrasonically guided needle biopsy (UGNB) of mediastinal masses was investigated in 45 patients. Fifteen of the masses were malignant and 30 were benign. The diagnoses were histologically confirmed by examination of surgical or autopsy specimens. Only teratoma could be confidently diagnosed by ultrasonography alone. Diagnosis of other types of mediastinal masses required examination of tissue samples. Using ultrasonically guided aspiration biopsy (UGAB), we were able to diagnose 13 of 15 malignant tumors and 18 of 27 benign mediastinal masses. Ultrasonically guided cutting biopsy was performed in conjunction with UGAB in 11 patients, and the diagnosis was histologically confirmed in 9 cases. Complications with UGNB occurred in only 1 case. Our results indicate that UGNB is a safe, simple technique that can be applied to most of the mediastinal masses. We believe that it is the method of choice in such cases.

Highly purified murine interleukin 5 (IL-5) stimulates eosinophil function and prolongs in vitro survival. IL-5 as an eosinophil chemotactic factor

The recent molecular cloning of the complementary DNA encoding T cell--replacing factor (TRF) has demonstrated that a single molecule is responsible for B cell growth factor II (BCGF-II) activity and eosinophil differentiation activity. It has been proposed that this molecule be called interleukin 5 (IL-5). We previously reported that purified rIL-5 supports the terminal differentiation and proliferation of eosinophilic precursors. In this study, we examined the effects of IL-5 on functional activities of mature eosinophils. IL-5 maintained the viability of mature eosinophils obtained from peritoneal exudate cells of mice infected with parasites. It also induced superoxide anion production in a dose-dependent manner. The Boyden's chamber Millipore assay revealed that IL-5 had a marked chemokinetic effect on eosinophils in a dose-dependent manner. Moreover, IL-5 was found to be an eosinophil chemotactic factor by the checkerboard assay. In conclusion, IL-5 is suggested to play an important role in increasing the functional activities of eosinophils as well as their production in allergic and parasitic diseases.

Ultrasonographic evaluation of pleural and chest wall invasion of lung cancer

The significance of ultrasonography was tested in evaluation of cancerous invasion into the pleura and chest wall in patients with lung cancer. The degree of the invasion was ultrasonographically classified into four grades, that is, uP-0, uP-1, uP-2 and uP-3, corresponding with the classification proposed by the Japan Lung Cancer Society, which is graded by surgical findings. The total accuracy of this method was 77 percent. Especially for uP-3, which is the most critical grade regarding decisions on surgical intervention, this figure was 100 percent. It is suggested that this approach can delineate cancerous invasion into the pleura and chest wall sufficiently well for daily clinical use and staging of patients with lung cancer.

Observation of lymph nodes and great vessels in the mediastinum by endoscopic ultrasonography

The mediastinum was studied by endoscopic ultrasonography in 121 lung cancer patients. This method facilitates the observation of the lymph nodes, the large vessels and heart in the mediastinum in real time and dynamically. In this paper, the orientation of mediastinal lymph nodes was ultrasonographically studied. This method can detect lymph nodes as small as 3 mm in diameter, and very highly those in bracheobronchial, subaortic, subcarinal, and hilar regions. The mediastinal vascular structures were also easily detected. This method can provide full clinical applicability for analysis of mediastinal involvements in lung cancer patients.