Anti-CTLA-4 Antibody Might Be Effective Against Non-small Cell Lung Cancer With Large Size Tumor

BACKGROUND/AIM

Immunotherapy using immune checkpoint inhibitors (ICIs) has revolutionized the treatment of advanced non-small cell lung cancer (NSCLC). Although several ICI options are available, the treatment regimen for NSCLC with large size tumors (large NSCLC) is controversial and the efficacy of anti-CTLA-4 antibody is unclear. This study thus investigated potential biomarkers for CTLA-4 blockade.

PATIENTS AND METHODS

The correlation between tumor diameter and treatment duration was examined in patients with advanced NSCLC treated with anti-PD-1 antibody monotherapy in our institution. In addition, the ratio of tumor-infiltrating CD8+ T cells and regulatory T (Treg) cells in small and large size NSCLC was also evaluated using immunohistochemical staining. Finally, the efficacy of treatment with anti-CTLA-4 antibody against large NSCLC was investigated.

RESULTS

A negative correlation was found between tumor diameter and treatment duration in patients treated with anti-PD-1 antibody monotherapy. Immuno-histochemical staining revealed that Treg cell infiltration was significantly higher in large NSCLC tumors than in small tumors. Among the patients with large NSCLC, the ICI regimen including anti-CTLA-4 antibody showed significant efficacies.

CONCLUSION

Anti-PD-1 antibody monotherapy might be less effective against large NSCLC due to the infiltration of Treg cells. Therefore, it might be appropriate for large NSCLC to select a treatment including an anti-CTLA-4 antibody, which can target Treg cells.

Computed tomography-based centrilobular emphysema subtypes relate with pulmonary function

Introduction:

Centrilobular emphysema (CLE) is recognized as low attenuation areas (LAA) with centrilobular pattern on high-resolution computed tomography (CT). However, several shapes of LAA are observed. Our preliminary study showed three types of LAA in CLE by CT-pathologic correlations. This study was performed to investigate whether the morphological features of LAA affect pulmonary functions.

Materials and Methods:

A total of 73 Japanese patients with stable CLE (63 males, 10 females) were evaluated visually by CT and classified into three subtypes based on the morphology of LAA including shape and sharpness of border; patients with CLE who shows round or oval LAA with well-defined border (Subtype A), polygonal or irregular-shaped LAA with ill-defined border (Subtype B), and irregular-shaped LAA with ill-defined border coalesced with each other (Subtype C). CT score, pulmonary function test and smoking index were compared among three subtypes.

Results:

Twenty (27%), 45 (62%) and 8 cases (11%) of the patients were grouped into Subtype A, Subtype B and Subtype C, respectively. In CT score and smoking index, both Subtype B and Subtype C were significantly higher than Subtype A. In FEV₁%, Subtype C was significantly lower than both Subtype A and Subtype B. In diffusing capacity of lung for carbon monoxide, Subtype B was significantly lower than Subtype A.

Conclusion:

The morphological differences of LAA may relate with an airflow limitation and alveolar diffusing capacity. To assess morphological features of LAA may be helpful for the expectation of respiratory function.

Classification of Centrilobular Emphysema Based on CT-Pathologic Correlations

Introduction:

Centrilobular emphysema (CLE) is recognized as low attenuation areas (LAA) with centrilobular distribution on high-resolution computed tomography. The LAA often exhibit a variety of shape or sharpness of border. This study was performed to elucidate the relationship between morphological features of LAA and pathological findings in CLE.

Materials and Methods:

The inflated-fixed lungs from 50 patients with CLE (42 males, 8 females; 14 operated, 36 autopsied) were examined by a method of CT-pathologic correlations that consisted of three steps. The first, CT images of the sliced lungs of the inflated-fixed lung specimens were examined on the shape and the peripheral border of each LAA. The second, the sliced lungs were radiographed in contact with high magnification. The third, the surface of the sliced lungs was observed by using stereomicroscopy. The views at low magnification of stereomicroscope were compared with the radiographs and the CT images of the same sample.

Results:

Using CT-pathologic correlations, LAAs of CLE were classified into three types as follows; round or oval shape with well-defined border (Type A), polygonal or irregular shape with ill-defined border and less than 5 mm in diameter (Type B), and irregular shape with ill-defined border and 5 mm or over in diameter (Type C). Type A, Type B and Type C LAA were mainly related to dilatation of bronchioles, destruction of proximal part of alveolar ducts, and destruction of distal part of alveolar ducts, respectively. Type A, Type B and Type C were dominant LAA in 5 (10%), 29 (58%) and 12 (24%) patients, respectively. However, remained 4 patients (8%) did not show dominant LAA type.

Conclusion:

Morphological features of LAA in CLE may depend on dilatation or destruction of certain parts of the secondary lobule. Type B LAA was the commonest type in CLE.

Role of lysine in interaction between surface protein peptides of Streptococcus gordonii and agglutinin peptide

INTRODUCTION

Streptococcus gordonii interacts with the salivary pellicle on the tooth surface and plays an important role in dental biofilm formation. Reports show that the analog Ssp peptide (A11K; alanine to lysine at position 11 in the arranged sequence, (1)DYQAKLAAYQAEL(13)) of SspA and SspB of S. gordonii increased binding to the salivary agglutinin (gp-340/DMBT1) peptide (scavenger receptor cysteine-rich domain 2: SRCRP2). To determine the role of lysine in the binding of the Ssp(A11K) peptide to SRCRP2, we investigated whether an additional substitution by lysine influenced the binding of Ssp(A11K) peptide to SRCRP2 using a BIAcore biosensor assay.

METHODS

Six analogs of the Ssp peptide with positive charges in surface positions on the structure were synthesized using substitution at various positions.

RESULTS

The binding activity of analog Ssp(A4K-A11K) peptide was significantly higher than the other Ssp analogs. The binding activity rose under low ionic strength conditions. The distance between positively charged amino acids in the Ssp(A4K-A11K) peptide between 4K and 11K was 1.24 +/- 0.02 nm and was close to the distance (1.19 +/- 0.00 nm) between Q and E, presenting a negative charged area, on SRCRP2 using chemical computing graphic analysis. The molecular angle connecting 1D-11K-4K in the Ssp(A4K-A11K) peptide secondary structure was smaller than the other peptide angles (1D-11K-XK). The Ssp(A4K-A11K) peptide showed higher inhibiting activity for Streptococcus mutans binding to saliva-coated hydroxyapatite than the (A11K) peptide.

CONCLUSION

The positioning of lysine is important for binding between Ssp peptide and SRCRP2, and the inhibiting effect on S. mutans binding to the tooth surface.

Secondary pulmonary alveolar proteinosis associated with myelodysplastic syndrome

A 47-year-old man, who had been diagnosed as myelodysplastic syndrome (MDS), complained of a severe cough and a high-grade fever. Chest CT disclosed scattered small nodules and ground-glass opacities with interlobular septal thickening in both lung fields and a mass lesion in the right lower lobe. Pathological findings of the ground-glass opacities and the mass lesion obtained by video-assisted thoracoscopic surgery revealed the accumulation of eosinophilic amorphous material in the alveoli and confirmed the diagnosis of pulmonary alveolar proteinosis (PAP). Autoantibodies against granulocyte-macrophage colony-stimulating factor (GM-CSF) in sera were below sensitivity, while the GM-CSF level was elevated in bronchoalveolar lavage fluid. He was diagnosed as secondary PAP associated with MDS.

[Investigation of practical application of fluorescence in situ hybridization (FISH) analysis using microwave irradiation in formalin-fixed, paraffin-embedded tissue sections]

We investigated fluorescence in situ hybridization (FISH) analysis using microwave irradiation in formalin-fixed, paraffin-embedded tissue sections of breast fibroadenoma. Higher percentage of cells with 2 signal copies of chromosome 3 centromere could be obtained in the condition of 5 microns thick sections, when we counted cells of more than 4 microns of nuclei in thickness. This method showed about the same results as FISH using cells separated from the same tissues. Percentage of cells with 2 signal copies of chromosome 17 centromere in 14 cases was 80.6 +/- 4.0% (Mean +/- S.D.). This method is expected in the application of the prognosis estimation of the breast cancer.

Pulmonary MALT lymphoma with amyloid production in a patient with primary Sjögren's syndrome

A 53-year-old woman was admitted to our hospital complaining of cough, low grade fever, chest pain and sicca symptoms. A chest radiograph showed an abnormal shadow and chest computed tomography revealed a tumor in left S6. She was diagnosed as Sjögren's syndrome by sialography and histological findings of labial biopsy. The surgically resected tumor specimen showed proliferation of lymphoid cells with lymphoepithelial lesions, which were positive for CD20 and kappa light chain. Kappa light chain-positive amyloid was found within the tumor. The tumor showed rearranged kappa light chain genes. The diagnosis was pulmonary mucosa associated lymphoid tissue lymphoma with amyloid production.

[A case of combined squamous cell carcinoma and aspergilloma arising in a cyst wall]

A 76-year-old man in whom interstitial pneumonia and diabetes mellitus had been diagnosed complained of bloody sputum in August, 1998. Chest radiography disclosed irregular shadows in the left lower lung field. Chest computed tomography (CT) scans revealed a cyst and a small nodular lesion in the left S6 segment. Although primary lung cancer was suspected, we did not detect any malignant cells in the transbronchial lung biopsy specimen. CT scans in January 2000 showed a ball-like shadow in the thick-walled cyst in the left S6 segment. Cytologic examination of the sputum and the bronchial lavage fluid from the left B6 revealed squamous cell carcinoma. Left lower lobectomy and mediastinal lymph node dissection were performed. Pathological examination revealed that moderately differentiated squamous cell carcinoma had extensively invaded the wall of the cyst in the left S6 and S10 segments, and was accompanied with aspergilloma. Abnormal thickening of a cyst wall may in some cases suggest the presence of lung cancer.

Three-year follow-up study of allergy in workers in a mushroom factory

Exposure to mushroom spores may cause many respiratory allergic diseases, however, there has been no serial study in a mushroom factory to address this problem. The aim of this study was to investigate the serial changes in respiratory allergy and the incidence of hypersensitivity pneumonitis (HP) in mushroom workers. A 3-year follow-up study, beginning in June 1996, was conducted in a newly operating mushroom factory in which one kind of mushroom is produced: Hypsizigus marmoreus (Bunashimeji). Allergic symptoms, chest roentgenogram, serum precipitins to the spores and soluble adhesion molecules in sera were evaluated once a year in 60 workers and 20 controls. Three out of the 60 subjects were diagnosed as having HP caused by inhalation ofthe mushroom spore and they were therefore excluded from this study, and the 57 non-HP subjects were evaluated. In this study 24 workers quit because of intolerable cough, runny nose, wheezing, sputum, fever elevation and/or shortness of breath at their place of work. During each year of this study as many as 70-80% of employees suffered some ofthe above symptoms, cough being the most frequent, and positive rate of serum precipitins to the spore revealed 30% in 1996, 93% in 1997 and 94% in 1998. From the June 1996 examination until the following May, serum soluble intercellular adhesion molecule-1 levels of the 15 workers who quit during that period were significantly higher than those in the 42 workers still employed in 1997 (P < 0.05). Workers in Bunashimeji mushroom factories might be at critical risk of developing respiratory allergy. In our 3-year study over 90% workers were sensitized to the spore, 40% quit because of the symptoms and 5% developed HP. It was suggested that workers should be counselled about the risk of mushroom allergy and precautionary measures should be taken to prevent its occurrence.

Chronic hypersensitivity pneumonitis induced by Shiitake mushroom spores associated with lung cancer

A 61-year-old man was admitted to our hospital with a 6-month history of productive cough. He, along with his wife, had been involved with Shiitake mushroom cultures for a period of 12 years. On admission, chest radiography showed bilateral fine-nodular shadow and CT scans showed reticulonodular opacities and a ground-glass appearance predominantly in the subpleural area in both lungs, and a mass in the left S6. Resected pathological specimens obtained by left lower lobectomy revealed lung adenosquamous carcinoma (stage IB), interstitial changes accompanied with lymphocyte proliferation and fibrosis, and granuloma with giant cells. Serum precipitins for Shiitake mushroom antigens were positive. The productive cough improved after the hospital admission and occurred again when he returned to work with the Shiitake mushroom production. Therefore, chronic hypersensitivity pneumonitis (HP) caused by Shiitake mushroom spores was diagnosed. Moreover, his wife was found to have HP caused by mushrooms at this time. There are only two previous reports of chronic HP caused by Shiitake mushroom in Japan, and this is the first case of chronic HP associated with lung cancer.

[The feasibility of a limited operation for primary lung cancer]

We reviewed 33 patients who underwent a limited operation for primary lung cancer between 1980 and 1998. These cases were divided into three groups; a poor risk group consisting of 18 patients who had a high risk such as pulmonary or cardiac dysfunction and who underwent partial resection of a lung, a reduction group consisting of 9 patients who had advanced lung cancer or uncontrolled cancer of an organ other than the lung and who underwent partial resection, and an active limited operation group consisting of 6 patients who underwent segmentectomy with lymphoadenectomy for the treatment of early lung cancer. The 1 and 3-year survival rates in the poor risk group, reduction group and active limited operation group were 73.9, 60.0, 100%, and 63.4, 0.0, 100%, respectively. The results of limited operations performed for poor risk cases were satisfactory in terms of both functional state and prognosis. Limited operations performed to reduce tumor in advanced lung cancer cases did not improve the prognosis. Although an active limited operation for a case of early lung cancer remains controversial with respect to indication, it is thought that this operation is not inferior to a standard radical operation (lobotomy with mediastinal lymphoadenectomy) in selective cases in which the maximum tumor diameter is 2 cm or less. The indication for a limited operation must be further examined from aspects of tumor size, tumor histology and the other factors of the tumor.

Serum surfactant proteins A and D as prognostic factors in idiopathic pulmonary fibrosis and their relationship to disease extent

Idiopathic pulmonary fibrosis (IPF) is a progressive, life-threatening, interstitial lung disease of unknown etiology. For optimal therapeutic management of IPF an accurate tool is required for discrimination between reversible and irreversible types of the disease. However, such noninvasive tools are few, and even with high-resolution computed tomography (HRCT), which is the most trusted method for doing so, the nature of the disease activity in IPF cannot always be accurately predicted. The aims of the present study were to assess the values of surfactant protein (SP)-A and SP-D in semiquantifying the extent of disease in IPF and in predicting deterioration in restrictive pulmonary function and survival over a follow-up period of 3-yr. SP-A and SP-D in sera were measured with enzyme-linked immunosorbent assays as previously described. Fifty-two IPF patients were studied to evaluate the association between serum SP-A and SP-D and disease extent on HRCT, deterioration in pulmonary function, and survival during 3 yr of follow-up. Both SP-A and SP-D concentrations were significantly correlated with the extent of alveolitis (a reversible change), whereas they did not correlate with the progression of fibrosis (an irreversible change). The SP-D concentration, unlike that of SP-A, was also related to the extent of parenchymal collapse and the rate of deterioration per year in pulmonary function. The concentrations of SP-A and SP-D in patients who died within 3 yr were significantly higher than in patients who were still alive after 3 yr. We propose that assays of SP-A and SP-D in sera from IPF patients are useful tools for understanding some pathologic characteristics of the disease, that SP-D may be a good predictive indicator of the rate of decline in pulmonary function, and that a combination of the assays for SP-A and SP-D may be helpful in predicting the outcome of patients with IPF.

Lobar distribution of emphysema in computed tomographic densitometric analysis

RATIONALE AND OBJECTIVES

The aims of this study were to determine the extent of emphysema in individual lobes and to investigate whether the lobar distribution of emphysema influences pulmonary function.

METHODS

Helical CT and pulmonary function tests were performed in 50 emphysema patients. Percentages of low attenuation volume (extent of emphysema) were calculated for each lobe by using CT densitometric analysis.

RESULTS

The extent of emphysema of the whole lung in these patients was 44%. Airflow limitation (r = -0.82, P<0.0001) and residual volume (r = -0.52, P<0.01) were closely correlated with the extent of emphysema in both lower lobes. Diffusing capacity (r = -0.61, P<0.0001) was closely correlated with the extent of emphysema in both upper lobes. On the basis of the lobar distribution of emphysema as determined by CT densitometry, we divided these emphysema patients into predominantly upper-lobe disease and predominantly lower-lobe disease groups. The predominantly lower-lobe disease group had significantly greater severe airflow limitation (P<0.0001), greater residual volume (P<0.01), and greater total lung capacity (P<0.05) than did the predominantly upper-lobe disease group.

CONCLUSIONS

CT densitometry showed a distinct lobar distribution of emphysema. Pulmonary function is significantly different between predominantly upper- and lower-lobe emphysema groups.

[Small cell lung cancer associated with anti-Hu antibody-positive paraneoplastic neurologic syndrome]

We report a case of small cell lung cancer with anti-Hu antibody-positive paraneoplastic neurologic syndrome preceded by variable neurological symptoms. A 57-year-old man first noticed a numbness on the inner side of his right leg in April 1998. He was later admitted to a hospital following the development of polyneuropathy, cerebellar dysfunction, and psychological symptoms. Chest plain X-ray films and computed tomographic scans disclosed a mass shadow in the right upper lobe, in addition to enlarged mediastinal lymph nodes. Small cell lung cancer was suspected on the basis of pathologic findings on an enlarged right supraclavicular lymph node and radiologic findings. The patient was referred to our hospital in October 1998. Anti-Hu antibody was detected both in serum and cerebrospinal fluid. Small cell lung cancer (clinical T1N3M0, stage IIIB) with paraneoplastic neurologic syndrome was diagnosed. Three courses of combination chemotherapy (carboplatin and etoposide) were administered with a partial response. However, the patient's neurological symptoms were not alleviated. We discussed the mechanism, clinical symptoms, and treatment of this disease.

[Compensatory increases in residual lobar volume following lung resection]

To investigate compensatory increases in residual lobar volume after lobectomy and pneumonectomy, we measured lung lobar volumes on the basis of pre- and postoperative computed tomographic (CT) images obtained on 40 patients (11 right upper, 7 right lower, 10 left upper, 8 left lower lobectomies and 4 left pneumonectomies). A personal computer image processing program was utilized to calculate lung lobar volumes from sequential CT images. Decreases in whole lung volume after lung resection averaged from 7.4% to 9.5% of preoperative whole lung volume in the lobectomy patients, and 30% in the patients who underwent left pneumonectomy. Those values were much smaller than the volumes of resected lobe, as measured on the basis of preoperative CT images. Increased residual lobar volume after lung resection averaged from 11% to 15% of preoperative whole lung volume in both the lobectomy and left pneumonectomy patient groups. Residual lobes compensated for approximately 60% of the resected lobar volume in the lobectomy patients, but only about 30% of resected lung volume in the left pneumonectomy patients. Increases in residual lobar volume tended to be larger in patients who underwent upper lobectomies, and on the operative side in patients other than those who underwent left lower lobectomies. We concluded that compensatory increases in residual lobar volume should be taken into full consideration when making predictions about postoperative pulmonary function.

[Perihilar interstitial bleeding due to thoracic endometriosis]

A 47-year-old woman was admitted to our hospital for evaluation of an abnormal shadow in the left hilar region. A CT scan showed a non-enhancing mass between the lingula and left basal bronchus. On the twelfth hospital day, when her menstruation began, she suddenly expectorated a large amount of blood, and her chest X-ray film showed enlargement of the mass in the left hilum and an infiltrative shadow in the left lung field. We suspected pulmonary endometriosis because the hemoptysis was synchronized with the menstruation and because of her history of operations for polyps in the uterine cervix. Six days after the episode of hemoptysis, magnetic resonance (MR) imaging demonstrated a fluid-fluid level in the mass on T 2-weighted images. The abnormal signals spread along the interstitium into the lung parenchyma, therefore we made a diagnosis of hemorrhage in the perihilar interstitium due to endometriosis. MR images obtained 20 days and 48 days after the episode of hemoptysis showed changes of intensity in the mass similar to those of intracranial bleeding. This was a rare case of endometriosis in the perihilar interstitium and it shows the usefulness of MR imaging in making the diagnosis.

Efficacy of ultrasonic mass survey for abdominal cancer

From August 1983 through March 1995, 204,099 people received ultrasonic mass survey of the abdomen for the first time. Among these examinees, 631 (0.31%) malignant neoplasm cases, such as 201 hepatocellular carcinoma (HCC), 81 gallbladder (GB) cancer, 57 pancreatic cancer, and 169 renal cell carcinoma (RCC), were detected. Three hundred seventy six out of 590 cases (64%), excluding chronic leukemia cases and metastatic liver cancer cases, were surgically resected. The resection rate of HCC, GB cancer, pancreatic cancer, and RCC were 25%, 88%, 49%, and 99%, respectively. The cumulative survival rate of the 376 resected cases was 79.5% at 10 years. The cumulative survival rates of resected cases of HCC, GB cancer, pancreatic cancer and cumulative survival rates of resected cases of HCC, GB cancer, pancreatic cancer and RCC were 34% at ten years, 83% at 10 years, 49% at 7 years, and 99% at 10 years, respectively. Ultrasonic mass survey is dramatically useful for early detection of various kinds of abdominal cancers, especially RCC and GB cancer. From now on, many earlier abdominal cancers will be found by establishing and promoting ultrasonic mass survey systems.

Pulmonary alveolar microlithiasis: high-resolution CT and MR findings

We report the high-resolution CT (HRCT) and MR findings in a case of pulmonary alveolar microlithiasis. HRCT revealed that the black pleural line on a chest radiograph was caused not by subpleural cysts but by a fat-dense layer between ribs and the calcified parenchyma. MRI showed both lower zones with diffusely increased signal intensity on T1-weighted images. We speculated it was caused by the accumulation of small-sized calcific particles.

[A case of sea water and sand aspiration during near drowning]

A 46-year-old man who had been pulled under water by a tidal wave when an earthquake occurred on July 12, 1993 was carried to our hospital the next day. He soon needed endotracheal intubation and mechanical ventilation because he expectorated sputa with sand and because arterial bloodgas analysis revealed severe hypoxemia. Chest X-ray on admission showed diffuse small nodules and areas of consolidation. Chest CT obtained on July 16 showed centrilobular small nodules bilaterally and alveolar opacities in the peribronchial region. After therapy with antibiotics and frequent bronchial lavages, sputum with sand disappeared on the 14 th hospital day and chest X-ray film and laboratory data showed marked improvement. He was discharged on October 1. A chest CT scan obtained on February 17, 1994 showed improvement of the small nodules. The areas of consolidation had also improved, but remained as linear and nodular opacities, which were considered to be organized lesions. There are few reports concerning radiographic findings particularly CT findings, after aspiration of sea water and sand during near drowning.

[Lung lobar volume in patients with chronic interstitial pneumonia]

We measured lung lobar volume by using helical computed tomography (HCT) in 23 patients with idiopathic interstitial pneumonia (IIP), 7 patients with chronic interstitial pneumonia associated with collagen vascular disease (CVD-IP), and 5 healthy volunteers. HCT scanning was done at the maximal inspiratory level and the resting end-expiratory level. To measure lung lobar volume, we traced the lobar margin on HCT images with a digitizer and calculated the lobar volume with a personal computer. The lower lobar volume and several factors influencing it in chronic interstitial pneumonia were studied. At the maximal inspiratory level, the lower lobar volume as a percent of the whole lung volume was 46.8 +/- 4.13% (mean +/- SD) in the volunteers, 39.5 +/- 6.19% in the patients with IIP, and 27.7 +/- 7.86% in the patients with CVD-IP. The lower lobar volumes in the patients were significantly lower than in the volunteers. Patients with IIP in whom autoantibody tests were positive had lower lobar volumes that were very low and were similar to those of patients with CVD-IP. These data suggest that collagen vascular disease may develop in patients with interstitial pneumonia. The patients with IIP who had emphysematous changes on the CT scans had smaller decreases in total lung capacity and lower ratios of forced expiratory volume in one second to forced vital capacity than did those who had no emphysematous changes, those two groups did not differ in the ratio of lower lobar volume to whole lung volume. This suggests that emphysematous change is not factor influencing lower lobar volume in patients with chronic interstitial pneumonia. We conclude that chronic interstitial pneumonia together with very low values for lower lobar volume may be a pulmonary manifestation of collagen vascular disease.

Regular and irregular dichotomies of bronchial branching in the human lung

RATIONALE AND OBJECTIVES

Typical models of the human bronchial tree depict regular branching. However, some anatomic studies also have revealed irregular dichotomies in the human lung. We therefore studied the patterns of bronchial branching in the human lung.

METHODS

We examined a normal right lung. Bronchial branchings were traced up to terminal bronchioles (TBs) in both regular and irregular dichotomies.

RESULTS

In 256 TBs in peripheral regions, the number of branchings varied from 11 to 23; the largest number was found in the S10c of the basal segment, and the average was 15. In 354 TBs in hilar regions supplied by irregular dichotomies, the number of branchings ranged from 9 to 15, with the average being 10. In secondary pulmonary lobules, bronchioles supplying the secondary pulmonary lobules reached TBs in two or three divisions.

CONCLUSION

Irregular dichotomies are too frequent to be neglected in the interpretation of radiologic and physiologic findings.

Lactic dehydrogenase-immunoglobulin G kappa complex in a patient with idiopathic interstitial pneumonia

A female patient with idiopathic interstitial pneumonia (IIP) was admitted again 40 months after the diagnosis due to progression of clinical findings and increased activity of serum lactic dehydrogenase (LDH). Analysis of LDH isoenzyme disclosed a broad band between LDH4 and LDH5. Gel filtration and immunoelectrophoresis showed that immunoglobulin (Ig) G (kappa type) bound the LDH. With prednisolone and azathioprine, her symptoms and radiological findings improved concomitant with a decrease in the serum LDH activity. The LDH-IgG kappa complex disappeared in the circulation 14 months after initiation of the therapy. We report circulating LDH-Ig complex in a patient with IIP, which may be related to the disease progression of IIP.

Relationships between radiological pattern and cell-mediated immune response in Mycoplasma pneumoniae pneumonia

The aim of this study was to determine the relationship between the radiological pattern of Mycoplasma pneumoniae and the level of cell-mediated immunity of the host. Computed tomographic (CT) scans of the chest and the results of the purified protein derivative (PPD) test were studied during the acute stage of infection in 54 patients with M. pneumoniae pneumonia. The CT findings were used to divide the patients into two groups: one group had a predominance of nodular opacities with a centrilobular distribution (Group N; n = 29); and the other showed a predominance of an airspace consolidation (Group C; n = 25). Forty out of 54 subjects had negative tuberculin skin tests ( < 10 mm induration). The positive rate of PPD reaction was higher in Group N (13 out of 29) compared to Group C (1 out of 25) (p = 0.0005); whilst pleural effusion appeared more frequently in Group C (10 out of 25) than in Group N (3 out of 29) (p = 0.023). There was no significant difference between Groups N and C in white blood cell and lymphocyte counts, level of antibodies to M. pneumoniae in sera, and severity of the disease. These findings suggest that the characteristics of the host cell-mediated immunity might influence the pattern of pulmonary lesions in M. pneumoniae infection.

[Comparative study on the efficacy of ritipenem acoxil and cefotiam hexetil in chronic lower respiratory tract infections by the double-blind method]

To objectively evaluate the efficacy, safety and usefulness of the newly developed penem oral antibiotic, ritipenem acoxil (RIPM-AC), against chronic lower respiratory tract infections, we conducted a multi-center double-blind comparative study using cefotiam hexetil (CTM-HE) as a control drug. RIPM-AC was orally administered at 200 mg, and CTM-HE at 400 mg, t.i.d. for 14 days, in principle. The results were as follows: The total number of patients enrolled in this trial was 202, of which 151 cases (RIPM-AC group: 75, CTM-HE group: 76) were evaluable for clinical efficacy. 1. The clinical efficacy rates (excellent+good) were 85.3% (64/75) in the RIPM-AC group and 80.3% (61/76) in the CTM-HE group. There was no significant difference between the two groups, hence the clinical equivalency of RIPM-AC to CTM-HE was demonstrated. 2. In the patients enrolled in the evaluation of clinical efficacy, the eradication rates of the causative organisms were 50.0% (13/26) in the RIPM-AC group and 75.0% (18/24) in the CTM-HE group, with no significant difference between the two groups. 3. Side effects were noted in 10 cases (11.0%) of the RIPM-AC group and 10 cases (10.9%) of the CTM-HE group. Abnormal laboratory test findings were observed in 8 cases(9.5%) of the RIPM-AC group and in 14 cases (16.7%) of the CTM-HE group. There were no significant differences between the two groups in the incidence of side effects and abnormal laboratory test findings. In the safety evaluation, RIPM-AC was judged to be safe in 73 cases (80.2%) and CTM-HE in 71 cases (77.2%), with no significant difference. 4. The usefulness rates (markedly useful+useful) were 79.5% (62/78) in the RIPM-AC group and 76.9% (60/78) in the CTM-HE group. There was no significant difference between the two groups. Since RIPM-AC showed clinical efficacy similar to those of CTM-HE and posed no particular safety problems, it is expected to be a useful antibiotic for the treatment of chronic lower respiratory tract infections.

Ontario's health-information service: a province-wide resource for patients

An innovative service based in Toronto provides consumers with specialized yet understandable information about health care and health promotion. The Consumer Health Information Service gathers articles from medical journals, periodicals, health agencies, support groups, books and medical databases to provide people with better access to readily understandable health information. Much health-related information is available, says the chief librarian, but often people have trouble determining where it is.

[Radiological and pathological analysis of the distribution of centrilobular emphysema in the transverse plane of the lung]

The distribution of centrilobular emphysematous lesions in the transverse plane was studied with high-resolution CT (HRCT) images of inflated and fixed lungs obtained from 49 patients with centrilobular emphysema (CLE). The transaxial distribution of low attenuation areas (LAA) was assessed quantitatively on HRCT images obtained from 21 patients. LAA in the outer layer accounted for a significantly lower ratio of the lung parenchyma than did those in the inner layer. Macroscopic analysis of 31 lobes obtained from 28 patients with CLE was done by point counting. The inner layer had many more LAA than the outer layer. Bronchiolar lesions were examined under the microscope for their relation to the observed variations in distribution in CLE. No significant differences were found in the bronchiolar lesions between the inner and outer layers. These data show a characteristic distribution pattern of CLE in the transverse plane. They also suggest that the disparity in distribution of LAA between the inner and outer layers is not influenced by the grade of bronchiolar pathological lesions.

U of T Medical School uses multistep strategy to prevent sexual harassment

The University of Toronto medical school is using a multistep strategy in an attempt to prevent sexual harassment among students and faculty members. A driving force behind the program is Dr. Miriam Rossi, who was recently appointed associate dean of student affairs. As well, the dean of medicine sent a notice to faculty members explaining that there will be zero tolerance "for any behaviour that can be construed to be sexual harassment."

[A case of Swyer-James syndrome--a morphological study with inflated fixed lung]

Morphological features of Swyer-James syndrome were studied in a specimen obtained during left pneumonectomy. A 67-year-old woman was admitted because her left lung was hyperlucent and contained a solitary nodule. Primary lung adenocarcinoma complicated with Swyer-James syndrome was diagnosed, and left pneumonectomy done. The left upper lobe was inflated and fixed for morphological study. The volume of the specimen was obviously lower than normal but the bronchial branching was normal. Macroscopically, the specimen had irregular bronchial walls, bronchiectatic changes, and dilation of distal air spaces, similar to panlobular emphysema. Microscopically, there was scarring in periarteriolar regions that suggested bronchiolitis obliterans, enlargement of distal airspaces, and an abnormally low number of capillaries. These findings suggest hypoplasia of the lung due to abnormal lung growth after birth.

Chronic eosinophilic pneumonia progressing to lung fibrosis

A 65 year old Japanese man was hospitalized with fever. Opacities distributed mainly in the subpleural regions were found on chest computed tomographic scan (CT), and these promptly cleared with corticosteroid therapy. Four years later, he presented with severe eosinophilia. Both chest X-ray and high resolution CT scan showed ground-glass opacities and honeycombing, suggesting lung fibrosis. A lung biopsy demonstrated intra-alveolar eosinophil infiltration, interstitial thickening with eosinophil infiltration, and a widely-distributed desquamative interstitial pneumonia-like reaction. With corticosteroid therapy, the ground-glass opacities decreased with a corresponding clinical improvement, although lung honeycombing and blood eosinophilia remained. In this case, circulating intercellular adhesion molecule-1 and circulating and bronchoalveolar lavage fluid eosinophil granule proteins were felt to be more effective markers for evaluating disease activity than the blood eosinophil number.

Soluble intercellular adhesion molecule-1 (ICAM-1) in sera and bronchoalveolar lavage fluid of patients with idiopathic pulmonary fibrosis and pulmonary sarcoidosis

ICAM-1 plays an important role in inflammatory diseases. To assess level of soluble ICAM-1 in the circulation and inflamed lesions, we measured levels of soluble ICAM-1 in the circulation and bronchoalveolar lavage fluid (BALF) of patients with idiopathic pulmonary fibrosis (IPF) and with pulmonary sarcoidosis (PS) and of healthy volunteers (HV), and we also analysed ICAM-1 expression of BALF cells in some patients and HV. IPF patients had significantly higher levels of circulating ICAM-1 than HV, while PS patients did not. By contrast, significantly increased levels of BALF soluble ICAM-1 were found in PS patients compared with those of HV, but not in IPF patients. There were no significant differences in the proportions of ICAM-1+ BALF lymphocytes in IPF patients, PS patients and HV, whereas significantly increased proportions of ICAM-1+ pulmonary alveolar macrophages were found in PS patients compared with those of HV, but not in IPF patients. There was a significant positive correlation of BALF soluble ICAM-1 levels to BALF lymphocyte proportions in PS patients. Although the source of BALF soluble ICAM-1 is unclear, BALF soluble ICAM-1 appears to reflect the grade of local activity of sarcoidosis. An interesting discrepancy between soluble ICAM-1 levels in the circulation and BALF was found in IPF patients, and this might be an important clue to an understanding of this disorder.

Circulating intercellular adhesion molecule-1 (ICAM-1) antigen in sera of patients with idiopathic pulmonary fibrosis

Intercellular adhesion molecule-1 (ICAM-1), a member of immunoglobulin supergene family with a five-domain structure, is known to play an important role in inflammatory diseases. An ELISA was developed using two MoAbs against human ICAM-1 in order to detect the soluble shedding ICAM-1 antigen in sera. We measured levels of circulating ICAM-1 antigen in sera of patients with idiopathic pulmonary fibrosis (IPF), pulmonary sarcoidosis, hypersensitive pneumonitis, bacterial and mycoplasmal pneumonia, and inflammatory diseases of other organs. The results clearly demonstrated that IPF had significantly high levels of circulating ICAM-1 in sera as compared with other disorders or normal controls. Moreover, immunohistochemical analysis with MoAb against human ICAM-1 disclosed that in IPF, the expression of ICAM-1 was intensively enhanced on alveolar epithelial cells. These results suggest that ICAM-1 may contribute to the pathogenesis of IPF.

[A case of chronic interstitial pneumonia with benign monoclonal gammopathy (IgM-k) and thrombocytopenia]

A 53-year-old woman was admitted on 13th October 1988 with symptoms of dry cough and shortness of breath persisting for 1 year. On physical examination, fine crackles were audible over her back. Chest X-ray showed bilateral reticulonodular shadows and collapse of the bilateral lower lobes. Chest CT showed patchy areas of increased density distributed predominantly in the subpleural zone. Laboratory data on admission showed thrombocytopenia, hypergammopathy (IgG, 2044 mg/dl; IgA, 286 mg/dl; IgM, 1645 mg/dl), and positive ANF. Further examinations demonstrated that anti-platelet and anti-centromere antibodies were positive in the serum, and the titer of PA-IgG was high (56 ng/10(7) platelets). Histopathological examination of the open lung biopsy demonstrated honeycombing and thickening of the alveolar walls, with slight infiltration of chronic inflammatory cells. These histopathological findings were comparable with usual interstitial pneumonia. We report a very rare case of chronic interstitial pneumonia complicated by benign monoclonal gammopathy and thrombocytopenia. Although it remains unclear, these abnormalities may have been caused by immunological mechanisms.

[A case of systemic arterial supply to normal lung without sequestrated lung]

A 19-year-old man was admitted to our hospital because of bloody sputum. His chest radiograph showed funicular shadows adjacent to the descending aorta in the left lower lobe and absence of vascular structures in the lower portion of the left hilum. His chest CT showed increased vascularity and slightly increased parenchymal density in the left basal segments. No cystic lesions were observed on CT. Angiographic examinations revealed that the left basal segments were supplied by an aberrant artery arising from the thoracic aorta, instead of the pulmonary artery. Left lower lobectomy was performed. Gross findings at surgery and histological examination confirmed the diagnosis of systemic arterial supply to normal lung without sequestrated lung. The main histological findings of the specimen were hemorrhage in alveolar spaces and dilatation of vessels. These findings seemed to correspond to the CT findings. We consider that CT is useful for the diagnosis of this disease.

Roentgenologic-pathologic correlations of miliary pulmonary metastases

To determine the accurate localization of nodules of miliary pulmonary metastases within the secondary lobules, a Roentgenologic-pathologic study was made, using an inflated and fixed lung that was excised at autopsy from a patient who died of small cell carcinoma of the left lower lobe. Nodules in the perilobular area and nonperilobular areas were counted using 1-mm-thick specimens and their radiographs. It was found that 78% of the metastatic nodules were located in the perilobular area and 22% in the nonperilobular area. Furthermore, 13% of the metastatic nodules in the perilobular area showed tumor thrombosis in the lymphatic vessels, while none of the metastases in the perilobular area showed any tumor thrombosis. These results suggest that miliary pulmonary metastases are predominantly distributed in the perilobular area and that this finding is helpful in the diagnosis of this disease when high resolution computed tomography is used.

[CT findings in panacinar emphysema]

We analyzed the CT images (in vivo) of 5 lobes (right middle lobe, 1; left lower lobe, 1; right lower lobe, 3) with panacinar emphysema (PAE) obtained at autopsy or thoracotomy for solitary lung tumor. The lobes were inflation-fixed by the method of Heitzman and sliced axially for a CT-pathologic correlative study. One lobe with mild PAE had normal appearance on CT; however, the other four lobes with PAE demonstrated low-attenuation areas (LAAs) of various shapes and sizes on CT. LAAs were locally distributed on CT slices in one lobe, dominant in the inner zones in two lobes, and diffuse in one lobe. Relatively normal to diminished vasculature was observed within the LAAs of four lobes. These CT findings differed significantly from those of centriacinar emphysema (CAE) as reported in other studies. We conclude that CT is useful in the clinical diagnosis of PAE and its differentiation from CAE.

[Qualitative assessment of centrilobular emphysema using computed tomography]

The ability of computed tomography (CT) in the qualitative assessment of centrilobular emphysema (CLE) was studied, with special reference to the morphological relationship between emphysematous change and relatively large bronchovascular bundle forming the margin of secondary pulmonary lobule. Three autopsied lobes with mild, moderate and severe CLE were fixed by the method of Heitzman. Then high resolution CT (HRCT) was applied to those inflation-fixed lobes, which allowed for direct one-to-one pathologic correlation. Furthermore, HRCT findings of these clinical cases with emphysema were analysed. Emphysematous change in CLE was observed as low-attenuation area (LAA) within the homogeneous background on Ct images. In mild and moderate cases, LAA's were round or oval in shape, however in severe case they were observed to be irregular in shape. The border between LAA and parenchyma was not clearly defined, however in severe case LAA was found to be bordered partially or rather subtotally by the bronchovascular bundle. In mild and moderate cases, LAA's were observed to be distant from relatively large bronchovascular bundle. On the other hand, in severe case, only a small amount of lung parenchyma was left between LAA and bronchovascular bundle. These findings correspond to morphologic characteristics of CLE, that is, the process of emphysematous change tends to take place in the center of the secondary lobule, and even if the lobe is severely destroyed, some portion of the peripheral acinus is still preserved at lobular margin. Thus, CT can help to identify the presence of CLE. Furthermore, CT scan analysis of severe grade emphysema may lead to the differentiation between CLE and panlobular emphysema.

A case of Trichosporon pullulans infection of the lung with adult T-cell leukemia

Fungal infections are often reported, but Trichosporon infection is very rare. A 78-year-old man with adult T-cell leukemia complicated with pulmonary infections is presented. Bronchial exudate culture revealed many yeast-like colonies, which were morphologically and biochemically identified as Trichosporon pullulans.

[CT-pathologic correlative study of interstitial pneumonia]

A direct CT-pathologic correlative study of interstitial pneumonia was performed using inflated and fixed lungs. The specimens, which were obtained from 26 patients at the time of autopsy or during surgery, had pathologic findings of interstitial pneumonia (UIP and/or DAD). The specimens were fixed in distension and air dried. They were then scanned with a GE CT/T9800. HRCT images of the specimens could be correlated with two different types of pathologic processes. One was the chronic fibrotic change which was seen in the subpleural area of the specimens both from the autopsied and surgical cases, and the other was the acute alveolar change which was seen in the diffuse area of the specimens only from autopsied cases. HRCT images of the chronic fibrotic change showed nodular opacities, ring like opacities, increased density (high density), and air-bronchiologram in the subpleural area. These findings were correlated with patchy fibrotic lesions, honeycombing, mucus stasis in cysts of the honeycomb, and dilatation of the airways. HRCT images of the acute alveolar change showed mainly diffuse increased densities (hazy appearance and high density) and diffuse nodular opacities. These findings were correlated with a diffuse thickening of the alveolar walls, hyaline membranes in the alveoli and alveolar ducts, and their organization. Understanding of the difference between HRCT images of these chronic and acute pathologic processes is helpful for the evaluation of disease processes of interstitial pneumonia by HRCT. The abnormal patterns of HRCT images of the specimens were influenced by several technical factors of CT scanning, such as reconstruction algorithm, thickness of the slice, window level, and window width. It is, therefore, necessary to know the influence to HRCT images by these technical factors for a better understanding of HRCT images in interstitial pneumonia.

Medicine in the Yukon: "this is the frontier and people need me"

Images

[CT in eosinophilic granuloma of the lung]

We analyzed the chest CT findings in nine patients with biopsy-proven eosinophilic granuloma. Multiple cystic lesions with relatively thin walls seems characteristic of this disease. Small nodular lesions and increased density were observed in many cases. Pleural or subpleural lesions were found in all cases. In seven cases, the distribution of the lesions were predominantly in the upper or upper and middle lung fields. In the remaining two cases however, lesions were found homogeneously throughout the whole lung. In order to analyze the site of the lesions in the secondary pulmonary lobule, a specimen obtained from an open lung biopsy was inflated and fixed using fixative by Heitzman's method. Observation of the slices of the specimen by dissection microscope and their soft X-ray radiographs demonstrated that the lesion existed in the central area of acini. However, CT of the patient before open lung biopsy didn't showed centriacinar distribution. The disparity is because a certain number of lesions lobule is necessary to identify the centriacinar pattern by CT.