Oxidative DNA damage in human esophageal cancer: clinicopathological analysis of 8-hydroxydeoxyguanosine and its repair enzyme

Both internal and external oxidative stresses act on DNA and can induce carcinogenesis. 8-hydroxydeoxyguanosine (8-OHdG) is an indicator of oxidative stress and it leads to transversion mutations and carcinogenesis. 8-OHdG is excision-repaired by 8-OHdG DNA glycosylase (OGG1). The purpose of this study is to clarify the effect of oxidative DNA damage and repair enzymes on esophageal carcinogenesis. The levels of 8-OHdG and OGG1 were immunohistochemically evaluated in resected specimens, including squamous cell carcinoma (SCC) in 97 patients with esophageal cancer. Higher levels of 8-OHdG in normal esophageal epithelium were associated with a higher smoking index (P = 0.0464). The 8-OHdG level was higher in cancerous areas than in normal epithelia (P = 0.0061), whereas OGG1 expression was weaker in cancerous areas than in normal epithelia (P < 0.0001). An increase of OGG1 expression in normal epithelium was observed as 8-OHdG levels increased (P = 0.0011). However, this correlation was not observed in cancerous areas. High OGG1 expression in the cytoplasm was related to deeper tumors (P = 0.0023), node metastasis (P = 0.0065) and stage (P = 0.0019). Oxidative DNA damage, which is attributable to smoking as well as disturbances in DNA repair systems, appears to be closely related to esophageal carcinogenesis and its progression.

Esophageal replacement by colon interposition with microvascular surgery for patients with thoracic esophageal cancer: the utility of superdrainage

Replacing the thoracic esophagus with the colon is one mode of reconstruction after esophagectomy for esophageal cancer. There is, however, a high incidence of postoperative necrosis of the transposed colon. This study evaluated the outcomes of colon interposition with the routine use of superdrainage by microvascular surgery. Twenty-one patients underwent colon interposition from 2004 to 2009. The strategy for colon interposition was to: (i) use the right hemicolon; (ii) reconstruct via the subcutaneous route; (iii) perform a microvascular venous anastomosis for all patients; and (iv) perform a microvascular arterial anastomosis when the arterial blood flow was insufficient. The clinicopathologic features, surgical findings, and outcomes were investigated. The colon was used because of a previous gastrectomy in 18 patients (85.7%) and synchronous gastric cancer in three patients (14.3%). Eight patients (38.1%) underwent preoperative chemoradiotherapy including three (14.3%) treated with definitive chemoradiotherapy. Seven patients (33.3%) underwent microvascular arterial anastomosis to supplement the right colon blood supply. Pneumonia occurred in four patients (19.0%). Anastomotic leakage was observed in five patients (23.8%); however, no colon necrosis was observed. The 3-year and 5-year overall survival rates were both 50.6%. Colon interposition with superdrainage results in successful treatment outcomes. This technique is one option for colon interposition employing the right hemicolon.

Acute lung injury following an esophagectomy for esophageal cancer, with special reference to the clinical factors and cytokine levels of peripheral blood and pleural drainage fluid

Acute lung injury (ALI) is one of most serious complications to occur after an esophagectomy for esophageal cancer. However, the pathogenesis of ALI is still unclear. The cytokine levels of pleural drainage fluid as well as peripheral blood were measured in 27 patients who had undergone an extended radical esophagectomy. Both the clinical factors and cytokine levels were compared between 11 patients with (group I) and 16 without ALI (group II). ALI occurred more frequently in patients who underwent colon interposition than in those who received a gastric tube reconstruction (86%vs 25%, P = 0.009). The operation time of group I was significantly longer than that of group II. A logistic regression analysis revealed colon interposition to be an independent factor associated with the ALI (P < 0.05). Postoperative anastomotic leakage and systemic inflammatory response syndrome (SIRS) occurred more frequently in group I than in group II (P < 0.01). Both the serum interleukin-6 (IL-6) and IL-8 levels of group I were significantly higher than those of group II. IL-1beta and tumor necrosis factor-alpha were undetectable in the peripheral blood, whereas they were detectable in the pleural effusion. The IL-1beta of pleural effusion was higher in group I than group II. In conclusion, greater surgical stress, such as a longer operative time, is thus considered to be associated with the first attack of ALI. The adverse events developing in the extra-thoracic site, such as necrosis and local infection around anastomosis may therefore be the second attack. Furthermore, ALI may cause not only SIRS but also other complications such as anastomotic leakage.

Recent advances in the surgical treatment for esophageal cancer in Japan: An experience of 1000 cases who underwent an esophagectomy at a single institute

15011

Background: Most cases of esophageal cancer are squamous cell carcinoma in Japan and the prognosis of such patients tends to be poor. However, the clinical results after an esophagectomy have recently been reported to improve. Methods: The mortality and morbidity as well as the patients’ prognosis were evaluated in 1000 cases of esophageal cancer who all underwent an esophagectomy in the Department of Surgery and Science (Department of Surgery II), Kyushu University, Japan from 1964 to 2006. The incidence of squamous cell carcinoma was 94 %. The patients were divided into three groups according to the operation period: Group I (n=197), Group II (n=432), and Group III (n=371) underwent an esophagectomy during the periods of ‘64-’80, ’81-’93, and ’93-’06, respectively. The incidences of TNM Stage 0 or I gradually increased (4, 19 and 24 %, respectively), while those of Stage IV decreased (28, 19 and 14 %). Results: The 5-yr overall survival rates (OSR) and cause-specific survival rate (CSR) after an esophagectomy for all 1000 cases were 30 and 37 %, respectively. The 5-yr OSRs of Groups I, II and III were 14, 27 and 46 %, while the 5-yr CSRs were 18, 36, and 52 %, respectively (P<0.01 between each group). When the prognoses were compared for each TNM stage, an improvement in the prognosis was observed at every tumor stage. A multivariate analysis (Cox proportional hazard model) revealed not only the age, depth of invasion, node metastasis, curability (each P<0.001) and extent of a lymphadenectomy (P<0.05) but also the operation period (P<0.001) to be independent prognostic factors. The morbidity rates of Groups I, II and III were 62, 38, and 33 %, and the incidences of pulmonary complications were 42, 13 and 14 %, respectively (P<0.01, Group I vs. II and I vs. III). The 30-day mortality rates were 8.1, 2.1 and 0 %, respectively (P<0.01 between each group). Conclusions: An analysis of a total of 1000 cases with esophageal cancer revealed that an esophagectomy has generally been safely performed without any critical pulmonary complications, while an increasingly favorable prognosis has been achieved due to recent advances in surgical techniques and treatment modalities.

No significant financial relationships to disclose.

Akt-mediated YB-1 phosphorylation induces resistance for chemotherapy of gastric cancer

4554

Background: Y-box-binding protein 1 (YB-1), a member of the DNA-binding protein family which contains a cold-shock domain, has pleiotropic functions in response to stimuli of the AKT/PI3K signal pathway. We have previously described a pathway that involves PTEN/AKT/PI3K, thereby mediating chemoresistance in gastric cancer patients. We studied the Akt-mediated YB-1 phosphorylation and resistance to anti-cancer drugs for the treatment of gastric cancer. Methods: Primary gastric carcinoma tissue and the corresponding normal mucosa were both obtained from 81 gastric cancer patients who underwent surgery in the Department of Surgery II at Kyushu University Hospital from the years 1996 to 2000. YB-1 nuclear expression was investigated by immunostaining while AKT activation was investigated by immunostaining with a phosphorylation-specific antibody. The chemotherapeutic sensibilities of these patients were investigated using an MTT assay. LOH of PTEN was studied using a DNA sequencer with D10S796 and D10S1173 microsatellite markers in the same samples. Results: We found the activated AKT to be associated with an increased resistance to multiple chemotherapeutic agents, including those currently used on gastric cancer patients (5-fluorouracil, adriamycin, mitomycin C, and cis-platinum). The YB-1 nuclear expression was recognized in some patients and they closely correlated with a high expression of phosphorylated AKT. A high level of AKT phosphorylation (activated AKT) correlated closely with the LOH of PTEN (p < 0.0008), and the prognosis of patients who had LOH of PTEN was significantly poor in comparison to the other patients. Conclusions: The results of this study indicate that AKT activation and LOH of PTEN mediated the YB-1 activation, thus suggesting that they play an important role in conferring broad-spectrum chemoresistance in gastric cancer patients. These findings thus support the carrying out of new clinical trials for investigations of combination chemotherapy using conventional drugs with a new generation of signal transduction inhibitors.

No significant financial relationships to disclose.

Phase I/II study of S-1 combined with triweekly irinotecan for advanced or recurrent colorectal cancer

14541

Background: A dose-escalation study of irinotecan (CPT-11) combined with S-1, an oral dihydropyrimidine dehydrogenase inhibitory fluoropyrimidine, was performed to determine the maximum-tolerated dose (MTD), recommended dose (RD), dose-limiting toxicities (DLTs), and objective response rate (RR) in advanced or recurrent colorectal cancer. Methods: The subjects were untreated patients with inoperable advanced or recurrent colorectal cancer aged 20–75 years. S-1 was administered orally at 80 mg m-2 day-1 from day 1 to 14 of a 21-day cycle and CPT-11 was given intravenously on day 1 at an initial dose of 80 mg m-2 day-1, stepping up to 150 mg m-2. The treatment was repeated every 3 weeks, unless disease progression was observed. Results: In the phase I portion, only one of six patients at level 1 (80 mg m-2 of CPT-11) developed DLT, grade 3 diarrhea. No other serious adverse reactions occurred (either hematological or non- hematological), and all patients at levels 2 (100 mg m-2) to 5 (150 mg m-2) could receive therapy safely on an outpatient basis. The final RD was determined to be 150 mg m-2. In the phase II portion, fourteen patients including three patients in the final RD phase I portion were evaluated. The median treatment course was six (range: 2–17). The incidences of severe (grade 3–4) haematological and nonhaematological toxicities were 41.7 and 8.3%, respectively, but all were manageable. The RR was 50% (7 of 14, 95%CI: 23.0–77.0%), and Disease Control Rate (PR + SD) was seen in 71.4%. MST is not reached. Conclusions: Our phase I/II trial showed that S-1 combined with CPT-11 achieved a high response rate and could be given safely on an outpatient basis. These findings suggest that the therapy has potential as first- line treatment for inoperable advanced recurrent colorectal cancer. The updated analysis will be presented at the meeting.

No significant financial relationships to disclose.

Impact of PTEN/AKT/PI3K signal pathway on the chemotherapy for gastric cancer

4034

Background: Growth factor receptor-mediated signal transduction has been recently implicated in conferring resistance to conventional chemotherapy on cancer cells. We have described a pathway that involves AKT/PI3K to mediate chemoresistance in gastric cancer patients. The phosphatase activity of PTEN is crucial in controlling the phosphatidylinositol-3 (PI-3) kinase signal transduction pathway and in the activation of the protein kinase B(PKB/Akt) proto-oncogene. This indicates that PTEN exerts its tumor-suppressor function by negatively regulating the anitapoptotic PI3-kinase/AKT signaling pathway. Methods: Primary gastric carcinoma tissues and corresponding normal mucosa were obtained from 119 gastric cancer patients who underwent surgery in the Department of Surgery II in Kyushu University Hospital from the years 1996 to 2000. Methylation of PTEN was studied with methylation-specific PCR and LOH (loss of heterozygosity) of PTEN was studied using a DNA sequencer with D10S796 and D10S1173 microsatellite marker in the same samples. AKT activation was investigated by immunostaining with a phosphorylation-specific antibody. The chemotherapeutic sensibilities of these patients were investigated using an MTT assay. Results: We found that methylation of PTEN was rarely recognized, However, the gastric cancer patients who had a higher AKT phosphorylation (activated AKT) appeared to have LOH of PTEN (p < 0.0008), and the prognosis of the patient who has LOH of PTEN was significantly poor. When the chemotherapeutic sensibilities of these patients were studied in an MTT assay, it was found that the activated AKT was associated with increased resistance to multiple chemotherapeutic agents, which included those currently used on gastric cancer patients (5-fluorouracil, adriamycin, mitomycin C, and cis-platinum). Conclusions: The results of this study indicate that AKT activation and LOH of PTEN plays an important role in conferring a broad-spectrum chemoresistance in gastric cancer patients. It also indicates that clinical trials for an appropriate chemotherapy combination with conventional drugs and a new generation of signal transduction inhibitors that inhibit the PTEN/AKT pathway should be considered in treating gastric cancer in the near future.

No significant financial relationships to disclose.

Clinical effects of esophagectomy for patients 80 years of age and older with thoracic esophageal cancer

4049

Background: Esophageal cancer tends to mainly occur in elderly patients. Although a radical operation is the most effective existing therapy, the associated operative morbidity is still high. As a result, the indications for an esophagectomy in elderly patients (especially for patients over 80 years of age) remain controversial. Methods: A total of 599 patients with thoracic esophageal cancer who underwent an esophagectomy by the transthoracic approach since 1986 were evaluated. They were divided into 3 groups depending on age, namely groups I (<69 y.o., n = 441), II (70–79 y.o., n = 143) and III (≥80 y.o., n = 15). No significant differences were observed in the location of the tumor, histological type or stage. A distal esophagectomy with a left thoracotomy was performed for 40, 46, and 47% of the patients, respectively, while the others underwent a subtotal esophagectomy with a right thoracotomy. In group III, surgery was only done for cases with PS 0 or 1 as well as a normal cardiac and pulmonary function (ejection fraction ≥65 %, vital capacity ≥80 %, FEV 1.0% > 70%). Results: Postoperative complications occurred in 31 % of group I and 39 % of group II patients, and the incidence of pulmonary complication was 9 and 18 %, respectively (P < 0.01). In group III, the operative morbidity and mortality were 27 and 0 %, respectively, and pulmonary complications only occurred in one patient (7%). No significant difference was observed in the disease-free survival (DFS: 50, 46 and 58 % for 3yrs, 44, 40 and 33 % for 5 yrs), while the overall survival rates were worse in the older groups as a result of death due to causes other than recurrence (45, 34 and 34 % for 3yrs and 38, 26 and 9 % for 5 yrs in groups I, II and III, respectively. P < 0.01 group I v.s. II). Conclusions: An esophagectomy is considered to be a viable treatment alternative in patients over 80 years of age without increasing morbidity, when the indications for surgery are strictly determined. Furthermore, the DFS in these patients was similar to that observed in younger patients although the incidence of death due to causes other than cancer was found to be higher. An esophagectomy should therefore be considered as an effective treatment strategy even in elderly patients over 80 years of age.

No significant financial relationships to disclose.

Spontaneous tumorigenesis in mice defective in the MTH1 gene encoding 8-oxo-dGTPase

Oxygen radicals, which can be produced through normal cellular metabolism, are thought to play an important role in mutagenesis and tumorigenesis. Among various classes of oxidative DNA damage, 8-oxo-7,8-dihydroguanine (8-oxoG) is most important because of its abundance and mutagenicity. The MTH1 gene encodes an enzyme that hydrolyzes 8-oxo-dGTP to monophosphate in the nucleotide pool, thereby preventing occurrence of transversion mutations. By means of gene targeting, we have established MTH1 gene-knockout cell lines and mice. When examined 18 months after birth, a greater number of tumors were formed in the lungs, livers, and stomachs of MTH1-deficient mice, as compared with wild-type mice. The MTH1-deficient mouse will provide a useful model for investigating the role of the MTH1 protein in normal conditions and under oxidative stress.

Analysis of MTH1 gene function in mice with targeted mutagenesis

Oxidative DNA damage is thought to contribute to carcinogenesis, ageing, and neurological degeneration. Further, the cumulative risk of cancer increases dramatically with age in humans. In general terms, cancer can be regarded as a degenerative disease of ageing. There is evidence for the accumulation of oxidative DNA damage with age based on studies mainly measuring an increase in 8-oxoguanine. 8-Oxo-7,8-dihydro-2'-deoxyguanosine 5'-triphosphate (8-oxo-dGTP) is formed in the nucleotide pool of a cell during normal cellular metabolism. When 8-oxoguanine is incorporated into DNA causes mutation. Organisms possess 8-oxo-dGTPase, an enzyme that specifically degrades 8-oxo-dGTP to 8-oxo-dGMP. To analyze the function of MTH1 with 8-oxo-dGTPase activity in vivo, we generated a mouse line carrying a mutant MTH1 allele created by targeted gene disruption. MTH1 homozygous mutant mice were found to have a physically normal appearance, but seemed to have lost 8-oxo-dGTPase activity in liver extracts. When we examined the susceptibility of the mutant mice to spontaneous tumorigenesis, no significant difference was observed in survival rate of MTH1+/+ and MTH1-/- mice. However, pathological examination revealed a statistically significant difference in the incidence of tumors. More tumors were formed in lungs, livers, and stomachs of MTH1-/- mice than in those of the wild type mice. These studies with MTH1-null mutant mice provided an important insight into the role of this nucleotide sanitization enzyme in terms of the spontaneous tumorigenesis as well as mutagenesis caused by the oxygen-induced DNA damage.

Prognostic significance of lymphocyte infiltration following preoperative chemoradiotherapy and hyperthermia for esophageal cancer

PURPOSE

Lymphocyte infiltration (LI) around cancerous lesions is an important immune response. The purpose of this study is to evaluate the prognostic significance of LI after preoperative treatment for esophageal cancer.

METHODS AND MATERIALS

Preoperative chemoradiotherapy (CR therapy), either bleomycin 30 mg or cisplatin 120 mg/m(2) plus radiation 30 Gy, was performed on 51 cases with esophageal cancer, while hyperthermo-chemoradiotherapy (HCR therapy) was also indicated in 71 cases. Using resected specimens, both the histopathologic effectiveness and degree of LI to cancerous lesions were evaluated.

RESULTS

The incidences of the cases in which preoperative treatment was effective were 56% and 92.3% in LI (-) and LI (++) group (p < 0.05). The presence of LI resulted in favorable prognosis; the 5-year survival rates of LI (++) and LI (+) patients were 75.5% and 46.1%, both of which were significantly better than LI (-) (27.8%, p < 0.05 and p < 0.01, respectively). Especially among cases whose preoperative treatment was moderately effective, a multivariate analysis revealed LI to be a favorable prognostic factor independent of other clinicopathologic factors (p = 0.0171). Regarding the preoperative treatment, the incidence of LI (++) was higher in the HCR group (16.9%) than in the CR group (2.0%, p < 0.01).

CONCLUSIONS

LI appears to be a prognostic predictor after preoperative CR therapy while, in addition, simultaneous hyperthermia may stimulate LI in cases with esophageal cancer.

CYFRA 21-1 determination in patients with esophageal squamous cell carcinoma: clinical utility for detection of recurrences

BACKGROUND

While there are reports that CYFRA 21-1 is a useful tumor marker, to our knowledge the clinical utility of this marker to detect recurrences for squamous cell carcinoma of the esophagus has not been addressed.

METHODS

By immunoradiometric assay, human serum levels of CYFRA 21-1, SCC antigen and CEA were measured in esophageal squamous cell carcinoma patients prior to their initial treatment. Monthly follow-ups of these tumor markers was done after surgery.

RESULTS

The diagnostic sensitivity of CYFRA 21-1 was 43.9% (18 of 41), a value superior to that for SCC antigen (26.8%) and CEA (17.0%) (P < 0.05). The positive rates of CYFRA 21-1 increased with progression of the disease, 22.2% of pTNM Stage 0-IIA and 77.8% of pTNM Stage IIB/III (P = 0.013), whereas SCC antigen and CEA rates were not related to pTNM stage. Among 13 patients with clinical evidence of a recurrence, 76.9% (10 of 13) exhibited an increase in CYFRA 21-1, and this increase was evident before clinical detection of the recurrence in 9 of these 13 patients (69.2%). Consequently, postoperative elevations of serum CYFRA 21-1 levels were indicative of a tumor recurrence 1-13 months before acquisition of clinical and radiological data.

CONCLUSIONS

The assay of CYFRA 21-1 is useful not only for diagnosis but also for close monitoring of patients with esophageal squamous cell carcinoma.

CYFRA 21-1 determination in patients with esophageal squamous cell carcinoma: clinical utility for detection of recurrences

BACKGROUND

While there are reports that CYFRA 21-1 is a useful tumor marker, to our knowledge the clinical utility of this marker to detect recurrences for squamous cell carcinoma of the esophagus has not been addressed.

METHODS

By immunoradiometric assay, human serum levels of CYFRA 21-1, SCC antigen and CEA were measured in esophageal squamous cell carcinoma patients prior to their initial treatment. Monthly follow-ups of these tumor markers was done after surgery.

RESULTS

The diagnostic sensitivity of CYFRA 21-1 was 43.9% (18 of 41), a value superior to that for SCC antigen (26.8%) and CEA (17.0%) (P < 0.05). The positive rates of CYFRA 21-1 increased with progression of the disease, 22.2% of pTNM Stage 0-IIA and 77.8% of pTNM Stage IIB/III (P = 0.013), whereas SCC antigen and CEA rates were not related to pTNM stage. Among 13 patients with clinical evidence of a recurrence, 76.9% (10 of 13) exhibited an increase in CYFRA 21-1, and this increase was evident before clinical detection of the recurrence in 9 of these 13 patients (69.2%). Consequently, postoperative elevations of serum CYFRA 21-1 levels were indicative of a tumor recurrence 1-13 months before acquisition of clinical and radiological data.

CONCLUSIONS

The assay of CYFRA 21-1 is useful not only for diagnosis but also for close monitoring of patients with esophageal squamous cell carcinoma.

Alcohol consumption and cigarette smoking in relation to high frequency of p53 protein accumulation in oesophageal squamous cell carcinoma in the Japanese

We investigated levels of p53 protein expression in Japanese patients with oesophageal squamous cell carcinoma. A significantly larger proportion of heavy alcohol drinkers and cigarette smokers was evident in the p53-positive group. The combination of drinking and smoking was associated with a high frequency of p53 protein accumulation.

[Copper supplement with cocoa for copper deficiency in patients with long-term enteral nutrition]

Copper deficiency (normal serum copper level: 78-136 micrograms/dl) has been reported in patients with long-term enteral nutrition, caused by a copper deficit in enteral nutrition. Occasionally, this leads to anemia and leukopenia. We used Hershey's pure cocoa that is rich in copper (content 3.8 mg/cocoa 100 g) for copper deficiency. A total of 86 (40 men and 46 women, mean age 69 years) patients on enteral nutrition were studied. The primary diseases were cerebral vascular disease in 71 patients, neurological disease in 5 and others in 10. Those who showed serum copper levels of 20 micrograms/dl or less (N = 8) were given 30-45 g of cocoa (copper content 1.14-1.71 mg) per day for about 40 days. Among them, two patients could not continue because of vomiting and diarrhea and were excluded from this study. Mean serum copper levels increased from 8.7 +/- 6.2 to 99.0 +/- 25.4 micrograms/dl (N = 6). Those who showed serum copper levels 20-77 mg/dl (N = 31) were given 10 g of cocoa (copper content 0.38 mg) per day for about 40 days. When mean serum copper levels increased from 50.5 +/- 19.3 to 89.0 +/- 12.9 micrograms/dl with cocoa administration, anemia and neutropenia caused by copper deficiency showed a tendency to improve. After completing the study period, cocoa was reduced to 5 g (copper content 0.19 mg) per day in 23 patients. The mean serum copper levels increased from 90.7 +/- 10.4 to 100.6 +/- 17.1 micrograms/dl for about 100 days. Recently, the amount of daily copper requirement for adults has been reported to be 1.28-2.5 mg per day. We showed that 10 g of cocoa (0.6 mg total copper: 0.38 mg in cocoa and 0.22 mg in other nutrients) is sufficient to treat copper deficiency, and 5 g of cocoa (0.37 mg total copper: 0.19 mg in cocoa and 0.18 mg in other nutrients) is enough to maintain the normal level of serum copper in patients with long-term enteral nutrition.

[Mechanism of leukocytapheresis effect in the treatment of ulcerative colitis]

To solve adverse effects of high dose steroid administration for patients with moderately severe and severe ulcerative colitis (UC), additional use of leukocytapheresis (LCAP) was tried to settle colonic inflammation. We evaluated immunological changes in the treatment of LCAP using leukocyte removal filter for UC patients. We then assessed the clinical effectiveness of LCAP compared with that of high dose of steroid therapy. LCAP removed monocytes, granulocytes, and lymphocytes presenting CD 11 b+, CD 11 c+, and HLADR+, selectively from the patients. Proinflammatory cytokine productions measured such as TNF alpha, IL-1 beta, and IL 8 reduced and IL 10 increased immediately after LCAP compared with before perfusion. Improved rate was about 70% for LCAP group and about 40% for high dose steroid group (Refer J Gastroenterol). Selective removal of granulocyte, monocytes, and activated lymphocytes inhibits proinflammatory cytokine production and increases immune modulating cytokine productions (Refer Therapeutic Apheresis). Then quick inhibition of several inflammatory deteriorated factors simultaneously controls the activity and clinical symptoms of UC with less severe adverse effects. It can be considered one option for treatment of UC.

[Leukocytapheresis for ulcerative colitis]

Leukocytapheresis(LCAP) and Granulocytapheresis(GCAP) are classified as extracorporeal circulation therapy(ECCT). These therapies are a novel, effective way to treat patients with ulcerative colitis(UC). During 7 weeks of intensive therapy(LCAP weekly, predonisolone(PSL) 30-80 mg/day), UC patients treated with LCAP revealed significant improvements on their subjective and objective symptoms compared to patients treated with PSL intravenous administration. Moreover, LCAP has been recognized as safer than other drugs for UC. In our previous study, only 9.9% out of 1,978 LCAP sessions showed some side effects, and most were mild and temporary. Therefore, LCAP could be the first choice to treat UC patients who resist and/or reveal severe complications against ordinary drug therapies.

Esophageal hemangioma: a case report and review of the literature

The patient, a 60-year-old man, was diagnosed as having a protruding lesion in the upper thoracic esophagus on a routine endoscopic examination. Endoscopy showed a polyp with a pedicle in the upper esophagus. A biopsy indicated the presence of hemangioma. Since endoscopic ultrasonography showed the tumor to be located within the mucosa and submucosa, we chose an endoscopic resection as the most appropriate treatment for the esophageal hemangioma. After endoscopic resection, the patient has remained free of any symptoms or recurrence. Although an esophageal hemangioma is a benign tumor, a risk of severe hemorrhaging does exist. We conclude that the first choice of the treatment for esophageal hemangioma should thus be an endoscopic resection if the tumor is located within the mucosal or submucosal layer. However, if it is impossible to resect endoscopically, then either endoscopic injection sclerotherapy (EIS) or a surgical resection should be considered.

Esophageal carcinoma showing a long stricture due to prominent lymphatic permeation: report of a case

Some esophageal diseases such as carcinoma, esophagitis, and collagen diseases have often been reported to show a diffusely thickened esophageal wall in the roentogenogram findings. In the current report, a preoperative upper gastrointestinal series and an endoscopic examination showed a diffusely infiltrative type carcinoma, but other examinations did not suggest any diseases such as esophagitis or collagen diseases which might cause a thickening of the esophageal wall or a constriction of the esophagus. A postoperative histological examination revealed the primary carcinoma to remain only within the mucosal layer, while a large degree of lymphatic vessel permeation reached the adventitia over a wide area. An extraordinary degree of lymphatic permeation spread through the esophageal wall, and stromal fibrosis developed as a result of such lymphatic permeation. These histological phenomena might thus have led to the macroscopic appearance of infiltrative type esophageal carcinoma.

Effect of leukocytapheresis therapy using a leukocyte removal filter in Crohn's disease

Eighteen patients with active Crohn's disease were treated with one leukocytapheresis session per week for a five-week intensive therapy, decreasing to one leukocytapheresis session per month for five sessions of initial maintenance therapy. Nutritional indices, inflammatory reactions, flow cytometry profiles, and cytokine production were also assessed before and after the intensive and initial maintenance therapy. Nine of the patients (50%) attained remission at the end of the intensive therapy. The nine non-remission patients had exhibited longer periods of suffering and more severely affected sites prior to the therapy. In 14 of 18 patients (77.8%), the nutritional indices, Internal Organization of Inflammatory Bowel Disease (IOIBD) score and Crohn's Disease Activity Index (CDAI) improved from the pretherapy levels, but only the remission group (50%) showed improvement in C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). The remission group showed significantly higher pretherapy CD4+ CD45+ cell ratios and interleukin-2 (IL-2) production than the non-remission group, and significantly lower activated cells.

[Aneurysm of the membranous ventricular septum with ventricular septal defect, mitral and tricuspid insufficiency]

A seventy-year-old man was admitted at our hospital because of dyspnea. Echocardiogram and left ventriculogram showed an aneurysm formation of the membranous ventricular septum and small left-to-right shunt through ventricular septum defect and also severe mitral and tricuspid insufficiency. Operation was performed after medical therapy for congestive heart failure. During operation, mitral leaflets showed no organic lesions nor prolapse, but the annulus was dilated. The cause of mitral insufficiency, we thought, might be congenital, and the annulus dilatation was caused of mitral insufficiency, we thought, might be congenital, and the annulus dilatation was caused to produce tricuspid insufficiency secondary. The ventricular septal communication became small (diameter; 5 mm) and was associated with aneurysm formation of the remaining portion of the membranous septum. And the aneurysm, protruding to the septal leaflet of tricuspid valves, enhanced tricuspid insufficiency. It was reported by many authors that the aneurysm formation was related to spontaneous closure of ventricular septal defect. Patients with small ventricular septal defect, without any symptoms, must be followed intensively, or they might get cardiac complications, such as arrhythmia, right ventricular outflow obstruction, tricuspid insufficiency, and so on.

Family aggregation of carcinoma of the hypopharynx and cervical esophagus: special reference to multiplicity of cancer in upper aerodigestive tract

The role of family history in the multiple occurrence of cancer in the upper aerodigestive tract (UADT) remains unclear. The family histories of close relatives were examined in 167 patients with either hypopharyngeal or cervical esophageal cancer (PhCe cancer) and in 167 control subjects with benign diseases. The odds ratio for PhCe cancer was 2.6 in relation to family history of UADT cancers. Based on the family histories of close relatives, 167 cases with PhCe cancer were divided into 3 groups (Group I, 18 cases with a family history of UADT cancer; Group II, 37 cases with a family history of other cancers; Group III, 112 cases with no family history of any cancers). The mean age of the cases in group I was 59.4, which was younger than in group III (64.2). Second primary squamous-cell carcinomas in the UADT were more frequently recognized in group I (39%) than in group III (11%). However, no differences were observed in the smoking and drinking habits of male patients between each group. These results thus suggest that a family history of UADT cancers appears to be associated with the multiple occurrence of UADT cancers as well as the development of PhCe cancer.

Complications of leukocytapheresis

Recently leukocytapheresis (LCAP) has attracted attention as a new therapy for ulcerative colitis. We reviewed the complications associated with LCAP carried out in our department during the period from December 1992 to September 1997. There were side effects during 195 (9.9%) of the 1,978 sessions performed, involving 47 (51.1%) of the 92 patients treated. Moderate reactions, which caused considerable discomfort to the patients and required the transient interruption of the administration or some medical treatment depending on the state, occurred during 31 (1.6%) of all therapy sessions, involving 15 (16%) patients. All patients recovered soon and never fell into a life-threateningly severe state. They also did not have any symptoms afterwards. The common side effects were nausea, vomiting, fever, chills, and nasal obstruction. Reactions such as palpitations, respiratory distress, or chest oppressions were common, especially when heparin sodium (HS) was used as the anticoagulant. The type and frequency of side effects depended somewhat on the length of the therapy series or the duration of one session. Other complications such as clotting in the leukocyte removal filter and/or blood line during administration were encountered frequently. These latter problems occurred during 46% of all sessions, but most of them had little significance. Sessions in which HS was used as the anticoagulant showed more severe clotting than those in which nafamostat mesilate (NM) was used. In our series, we experienced a relatively low rate of serious complications. We require, of course, careful observation during and after each session.

Clinicopathologic features of patients with oesophageal cancer obtaining a histological complete response for preoperative hyperthermo-chemo-radiotherapy

From 1979 to 1993, 151 patients with resectable oesophageal cancer underwent preoperative hyperthermo-chemo-radiotherapy (HCR) followed by a subtotal esophagectomy. All resected specimens were histopathologically evaluated, and then were classified into two groups according to the efficacy of the preoperative HCR. Group A included 33 patients whose resected oesophagus was free of any cancer cells (grade 3). Group B included 118 patients, in which viable cancer cells remained in the resected specimens to various degrees (grade 1,2). The incidence of patients with well differentiated squamous cell carcinoma, node negative cases, or TNM stage I/II was significantly higher in group A than in group B (27.3% versus 9.3%, 72.7% versus 50.8%, 72.7% versus 50.8%, respectively). The recurrence rate was 33.3% (11/33) in group A, while it was 65.3% (77/118) in group B (p < 0.005). There was no case with any local recurrence in the former, while it was 8.5% (10/118) in the latter. The 1-, 3- and 5-year survival rates were 87.2%, 65.9% and 46.1% in group A, while they were 54.8%, 26.7% and 18.8% in group B (p < 0.005), respectively. Preoperative HCR may be expected of decreasing in the recurrence rate, including regional relapse when a grade 3 is obtained. Complete local control would further positively influence the prognosis.

Exacerbated autoimmune hepatitis successfully treated with leukocytapheresis and bilirubin adsorption therapy

A 58-year-old man with subacute fulminant onset of autoimmune hepatitis (AIH) was treated by leukocytapheresis (LCAP) and bilirubin adsorption therapy (BAT), rather than by administration of high-dose corticosteroids as he had mild glucose intolerance, and a definitive diagnosis of AIH was not obtained on admission; further, there was a risk of viral infection. After initiation of the therapies, serum transaminases and bilirubin, immunoglobulins, anti-nuclear antibodies, and rheumatoid factor decreased rapidly, as did the initially high levels of activated cells and several pro-inflammatory cytokines. Liver inflammation observed on liver biopsy settled during the course of the therapies, with no adverse side effects. A pause in the therapies was associated with deterioration; however, restoration of apheresis was followed by normalization. Remission was sustained throughout the period monitored, except for a recurrence 14 months after discharge, which was successfully resolved by two additional LCAP sessions. These results suggest that LCAP influences the causal mechanism(s) of exacerbation of AIH.

Leukocytapheresis with leukocyte removal filter as new therapy for ulcerative colitis

Leukocytapheresis (LCAP) with a leukocyte removal filter column was administered for 45 patients with ulcerative colitis (UC). We evaluated changes in the leukocyte count and the differential percentages during LCAP. Cytokine production was assessed from each patient's peripheral mononuclear cells or monocytes. Flow cytometry was performed to assess the removal rates of activated cells and adhesion molecule positive cells by LCAP. Clinical improvement was recognized in 35 of 45 patients during intensive LCAP therapy, and it continued throughout maintenance therapy in 32 patients (71.1%). The leukocyte count was decreased to about 40% during the first 30 min, but it increased to approximately 170% at 20 min after the completion of LCAP. The concentration of tumor necrosis factor (TNF)alpha before LCAP in the effective group was higher than it was in either the ineffective group or the control group. Its level decreased to near normal range after LCAP. In the effective group, the concentrations of interleukin (IL)-1beta, IL-2, interferon (IFN)gamma, and IL-8 were near the normal upper limits before LCAP; however, they had decreased after LCAP. The concentration of IL-4 increased after LCAP. In the ineffective group, in contrast, the concentrations had been at or near normal before the initial LCAP treatment. Flow cytometry study revealed that LCAP could remove the activated cells and adhesion molecule positive cells more effectively. The clinical improvement and the changes observed before and after LCAP therapy suggest that LCAP is able to intervene in the causal mechanism(s) of UC.

[Leukocytapheresis for ulcerative colitis]

Major inclusion criteria for leukocytapheresis (LCAP) therapy were mainly insufficient response to conventional drugs therapy. LCAP was administered once a week for 5 weeks of intensive therapy and once approximately a month for maintenance therapy, for 38 patients with UC. LCAP could remove approximately 1 x 10(10) white blood cells in each session. In the evaluation, we classified the response to the LCAP as: 1) excellent, 2) moderately improved, 3) no change, and 4) deterioration. Clinical improvement was recognized in 29 of 38 patients (76%) including 8 with dramatic response during the intensive therapy, and continued throughout the maintenance therapy in 26 patients (68.4%). Even though their symptoms were mild, the patients with more than 5 years UC history seemed to be not effective. The patients with moderately improvement and with excellent response have kept remission for about 20 months and about 2.5 years on an average, respectively. Clinical and blood examinations showed no side effects in any cases. It suggests that LCAP is able to be a UC treatment between drug therapies and an operation.

[Remission by leukocytapheresis for a patient with ulcerative colitis found refractory by conventional drug therapies]

A 40-year-old male was admitted to our hospital on August 30, 1994 to receive a new ulcerative colitis (UC) therapy, leukocytapheresis (LCAP). On the admission day, he had bloody stool 5 to 6 times/day, abdominal pain, slight fever, and hypoproteinemia. His UC type was moderately severe left-sided colitis with pseudopolyposis. Prior to admission to our hospital, his condition had not improved for about 9 months, despite drug therapies such as salicylazosulphapyridine, intravenous high dose prednisolone, protease inhibitor, intraarterial hydrocortisone sodium succinate, 4 series of pulse therapies with metylpredonisolone, enema of corticosteroid, azathioprine (Imuran), and cyclosporine at another hospital. Thus he was introduced to our college hospital and treated by LCAP since September 1. After 10 LCAP sessions, remission was observed and the patient discharged on December 23. Until he was later operated on for heavy bleeding after he had discontinued treatment and had drunk heavily, he had maintained remission for 13 months with LCAP only once a month even after we gradually decreased the other medical supports and stopped all of them. After LCAP, the normalization of high percentage of leukocytes presented HLADR+ and lymphocytes presented CD 11 a+ CD 8+ was also observed. This suggests LCAP intercepts the excess immune reaction in UC by removing leukocytes.

Effect of the sugar chain of soluble recombinant CD59 on complement inhibitory activity

A soluble recombinant CD59#77 (rCD59#77), consisting of 77 amino acids starting from the N terminus of membrane-bound CD59, was prepared using a gene expression system in CHO cells. The rCD59#77 preparation was composed of glycosylated and non-glycosylated forms (G and NG forms). Unexpectedly, NG form was 7 times more potent than G form in complement inhibitory activity. Postulating that sialic acids on G-form molecules make it difficult for rCD59#77 to access nascent membrane attack complexes on the cell surface, the sialic acids were removed by neuraminidase treatment. However, the inhibitory activity was not changed. Next, one of two putative N-glycosylation sites was mutated by substituting Gln18 for Asn18. The mutant, designated rCD59#77(N/Q), had no sugar moiety and was as active as the NG form of rCD59#77. These results suggest that the bulky sugar moiety at Asn18 is not necessary for the complement-inhibitory activity of rCD59 and actually hampers that function.

[Surgery for aortic valvular disease with congenital quadricuspid aortic valve]

A case of quadricuspid aortic valve is reported. A 69-year-old man was hospitalized with chest oppression at rest and abnormal electrocardiogram and diagnosed aortic regurgitation by echocardiography and aortic angiography. Aortic regurgitation was grade III according to Seller. Aortic valve replacement was performed successfully with a 21 mm St. Jude Medical valve. The aortic valve showed four cusps consisting of two equal larger cusps and two equal smaller cusps which was type C according to Hurwitz. Each valve was thickened and adhered, and fenestrations were found at each commissure. The right coronary ostium was small but not displaced. Twenty five cases in literature which were corrected surgically are also reviewed. Quadricuspid aortic valve is a rare anomaly but must be considered as a malformation which leads to severe valve failure in later life.

[Surgical treatment for active infective endocarditis]

Between April 1975 and December 1995, 33 patients with active infective endocarditis underwent surgical treatment at our hospital. The location of diseased valve was shown as ; 18 in aortic, 11 in mitral, and 4 in aortic and mitral position. Of these, 14 patients had an annular abscess or mycotic aneurysm. All patients achieved antibiotic therapy previously, and predominant indication for operation was congestive heart failure. All patients underwent valve replacement. The reconstructive procedures for 14 patients with paravalvular involvement were as follows ; direct closure : 5 cases, direct closure+tilted prosthesis technique : 5 cases, and another 4 cases were, patch closure of VSP resulting from a septal abscess, patch closure+translocation, translocation, and reconstruction of annulas with pericardial patch. There were five (15.2%) operative and hospital deaths and actuarial survival rate was 81% and 61% at 5 and 10 years after operation. Including one who died early after operation, there were 5 cases with postoperative paravalvular leakage and its main cause were persistent infection. In conclusion, it considered that the principles of treating active infective endocarditis is to decide the optimal timing for operation, debride the infected tissue, and close the defect completely.

Aortic valve replacement for aortic regurgitation due to Kawasaki disease. Report of two cases

Two cases of severe aortic regurgitation due to Kawasaki disease are reported. Both patients were diagnosed as having Kawasaki disease in their infancy, and were followed up by a pediatrician. Aortic regurgitation was detected 18 months in one case and 36 days in the other case after onset of the illness. With the passage of time, the aortic regurgitation increased and aortic valve replacement was scheduled in both patient at the age of 13. On admission, two-dimensional echocardiography showed thickening of the aortic cusps, and severe aortic regurgitation was detected by color flow Doppler studies. Successful aortic valve replacement was performed, and histological studies of the cusps showed sequelae of valvulitis. In conclusion, aortic regurgitation is a rare complication of Kawasaki disease, and the aortic valve function, especially occurrence of aortic regurgitation, should be carefully observed in patients with a past history of Kawasaki disease.

[Reconstructive surgery for acquired mitral regurgitation]

Between December, 1967, and July, 1994, 96 patients underwent repair of the mitral valve for acquired mitral valve regurgitation. According to Carpentier's classification, mitral valve pathology resulting in valve regurgitation was classified into three types; 4 patients assigned to type I, 63 type II, and 29 type III. The operative mortality rate was 1.0%. Follow-up data were available in 95 patients from 0.5 year to 25.3 years (mean average 8.8 years). The late mortality rate were not different between patients with valve pathology of type I, II and those with valve pathology of type III. Thromboembolism occurred on three patients for an embolic rate of 0.4% per patient-years. Twenty-eight patients required reoperation for residual MR and dehiscence of suture lines (type II; 10 cases, reoperation-free rate at 20 years, 83.2%) or recurrent MR due to progression of valve deformity (type III, 18 cases, reoperation-free rate at 20 years, 14.8%). These results demonstrate that patients with type I and II valve are good candidates for MVP, and that high incidence of reoperation for recurrent MR may limit the application of MVP to selected patients with type III valve.