Accurate and rapid novel genetic diagnosis for detection of sentinel lymph node metastasis in breast cancer patients

Background:

The transcription-reverse transcription concerted reaction (TRC) test is a novel molecular-based procedure, which can assess nodal metastasis accurately and quickly. We examined the usefulness of the TRC test with a double marker, cytokeratin 19 (CK19) and carcinoembryonic antigen (CEA) mRNA, to detect sentinel lymph nodes (SLN) metastasis in breast cancer patients.

Methods:

A total of 264 SLNs from 131 breast cancer patients were assigned to a training set (109 SLNs from 50 patients) and validation set (155 SLNs from 81 patients). Cytokeratin 19 and CEA mRNA were detected by TRC tests, and the sensitivity and specificity of the SLN metastasis between the TRC and histology cohorts were compared.

Results:

Mean copy numbers of CK19 and CEA by TRC tests were increased according to the metastatic size. In the training set, TRC test showed 100% sensitivity, specificity and concordance rates against the permanent histopathology test. In the validation set, sensitivity was 97.1%, specificity was 99.2% and the concordance rate was 99.4%.

Conclusion:

Our results showed that the detection of CK19 and CEA mRNA using the TRC test is, an accurate and rapid method for detection of SLN metastasis and can be applied as an intraoperative molecular diagnosis in breast cancer patients.

A novel rapid genetic diagnosis for peritoneal recurrence in gastrointestinal cancer patients

21052

Background: The prediction of peritoneal recurrence in gastrointestinal cancer patients is extremely important in order to prevent an unfavorable prognosis. The aim of our study was to evaluate the usefulness of a novel rapid RNA amplification system with transcription-reverse transcription concerted reaction (TRC) to detect isolated tumor cells in peritoneal washes of gastrointestinal cancer patients as an intra-operative genetic predictor of peritoneal recurrence. To clarify the characteristic qualities of TRC, we compared the results with those of one-step real-time RT-PCR. Methods: A total of 325 cytology-negative gastrointestinal cancer patients (164 gastric cancer, 161 colorectal cancer) were included. This study was approved by the institutional review board of our hospital and all patients provided written informed consent. Peritoneal washes of Douglas cavity were collected from patients. One-half of each wash was used for cytopathology and the other half was used for molecular diagnosis. Total RNA was extracted from cells which were separated from washes, and TRC and one-step real-time RT-PCR of multiple marker genes (CEA, CK20 mRNA) were performed using a TRCRapid-160 and LightCycler, respectively. Results: The rapidity and simplicity of the TRC is superior to that of one-step real-time RT-PCR. The detection time of marker genes by TRC was only 20 minutes as compared to 70 minutes of real-time RT-PCR. The sensitivity and reproducibility of the TRC were equal to those of real-time RT-PCR. Molecular detection of CEA and/or CK20 transcripts of the peritoneal washes by TRC showed a significant correlation to the depth of invasion, venous invasion, lymph node invasion, lymph node metastasis, peritoneal metastasis and stage. The peritoneal recurrence- free and overall survival rates of CEA and/or CK20 transcript-positive patients were significantly shorter than those of marker gene-negative patients. CEA and/or CK20 transcripts in peritoneal washes were independent prognostic factors of peritoneal recurrence-free survival and overall survival. Conclusion: TRC may be more useful than real-time RT-PCR due to its rapidity and simplicity for the intra-operative genetic diagnosis of peritoneal recurrence in patients with gastric and colorectal cancer.

No significant financial relationships to disclose.

Effect of immunotherapy and spleen preservation on immunological function in patients with gastric cancer

Splenectomy is often performed in patients who undergo total gastrectomy for cancer of the upper stomach. Although splenectomy facilitates lymph node dissection of the splenic hilum and recent reports advocate spleen preservation, the role of the spleen is not fully elucidated in gastric cancer treatment. This prospective randomized study was performed to evaluate the role of the spleen in immunological function in gastric cancer patients who underwent total gastrectomy and received postoperative immunochemotherapy. Forty-five patients with gastric cancer were randomly allocated to four groups: 1. splenectomy without immunotherapy (OK-432 administration), 2. splenectomy with immunotherapy, 3. spleen preservation without immunotherapy, 4. spleen preservation with immunotherapy. Postoperative immunological function of these patients was compared among the four groups. NK cell activity of the peripheral blood lymphocytes (PBL) in spleen-preserved patients who received immunotherapy was significantly higher for 24 weeks after surgery than that of the splenectomized patients with and without OK-432 administration. IL-2 production of PBL in spleen-preserved patients with immunotherapy was significantly higher between 4 and 24 weeks after surgery compared with that of the splenectomized patients without immunotherapy. The results suggest that spleen preservation might be beneficial in patients with less advanced gastric cancer who receive postoperative immunochemotherapy after total gastrectomy.

Phase I clinical trial of hybrid cell vaccination in patients with gastrointestinal cancer

2579

Background: Vaccination with hybrid cells of dendritic cells (DCs) and tumor cells can induce specific ant-tumor immunity against multiple tumor antigens including those that are unknown. We report the results of phase I study of hybrid cell vaccines comprised of autologous DC and autologous tumor cells in patients with Stage IV or recurrent gastrointestinal cancer. Method: Thirteen patients with Stage IV or recurrent gastrointestinal cancer were enrolled in this study after informed consent was obtained. Tumor cells were cryopreserved following acquisition from the primary or a metastatic site. DCs were induced from mononuclear cells of patients by culture with cytokines (6 days culture with GM-CSF and IL-4, and a further 1 day culture with TNF-α, IL-1 β, IL-6 and PGE2). Fusion of irradiated tumor cells and DC was created with a combination of PEG and electrofusion (two-step fusion method). At 2 week interval, patients received 4 freshly prepared fusion vaccines, with a constant dose range of 1 × 107 to 4 × 107 cells. The endpoints of this study were assessments of safety, anti-tumor immune response and clinical response. Results: Serious adverse events were not observed in any of the enrolled patients and all Common Toxicity Criteria were grade I. Clinical responses are 1 with partial response (PR), 5 with stable disease (SD) and 7 with progressive disease (PD). Delayed skin tests changed to positive in 5 patients. In patients with PR and SD, a shift to Th1 in Th1/Th2 balance of lymphocytes (IFN γ/IL10, IFN γ/IL4) was demonstrated by ELISPOT and cytokine flow cytometry analysis. After vaccination, decrease of immunosuppressive factors (IAP, TGF-β) in serum were shown in patients with PR and SD. There was no significant differences of CD4+CD25+ cells by vaccination. Conclusion: These results suggests that a strategy of hybrid cell vaccine employing auto-DCs and auto-tumor cells is feasible in patients with gastrointestinal cancer and may show evidence of anti-tumor immune response.

No significant financial relationships to disclose.

Dendritic cell vaccine therapy by immunization with fusion cells of interleukin-2 gene-transduced, spleen-derived dendritic cells and tumour cells

We examined the preventive and therapeutic effects of fusion cells prepared from spleen-derived dendritic cells (DCs) transduced with the interleukin-2 (IL-2) gene and QRsP fibrosarcoma cells in a mouse lung metastasis model. The IL-2 or LacZ gene was introduced into spleen-derived DCs using an adenoviral vector. Irradiated QRsP tumour cells were fused with IL-2 gene-transduced DCs (fusion/IL-2) or LacZ gene-transduced DCs (fusion/LacZ) by polyethylene glycol. These fusion cells expressed major histocompatibility complexes (MHC) class I and II, CD86, CD11c and CD8alpha. Splenocytes from mice vaccinated with fusion cells showed increased production of interferon-gamma (IFN-gamma) and cytotoxic T-lymphocyte (CTL) activity as compared with those vaccinated with DCs or tumour cells alone, and CTL levels were higher in fusion/IL-2-vaccinated mice than in fusion/LacZ-vaccinated mice. In our experiments on the protective and therapeutic effects on lung metastasis, mice vaccinated with fusion/IL-2 fusion/LacZ or fusion showed a significant reduction in pulmonary metastasis compared with those given DCs, tumour or phosphate-buffered saline. The introduction of the IL-2 gene into fusion cells produced more potent preventive and therapeutic effects. These results suggest that immunization with fusion cells prepared from spleen-derived DCs and tumour cells is capable of inducing preventive and therapeutic anti-tumour immunity against lung metastasis, and modification by the IL-2 gene may increase anti-tumour efficacy.

Segmental intestinal preservation and enteral nutrition help to maintain the intestinal function after a massive intestinal resection: report of a case

We report a case in which both segmental intestinal preservation and enteral nutrition helped to maintain the intestinal function after a massive bowel resection for superior mesenteric artery (SMA) thrombosis. A 53-year-old Japanese man was admitted to our hospital with acute abdomen. Extensive necrosis of the small intestine was found during the operation; however, a loop of the ileum appeared to be viable. A massive resection of the small intestine which preserved a 50-cm length of the viable ileum loop was thus performed. However, diffuse stenosis of the remaining ileum was found after surgery. An end-to-end anastomosis of the distal end of the preserved ileum loop and the terminal ileum was made in the second operation, and enteral nutrition was infused to improve the remnant intestinal function. A jejunoileostomy was performed in the final operation. An X-ray study after the final operation showed the stenosis of the remaining ileum to have improved. The patient therefore did not need any nutritional support after being discharged.

Spontaneous reduction in Epstein-Barr virus (EBV) DNA copy number in EBV-infected epithelial cell lines

We found that spontaneous and 12-0-tetradecanoylphorbol-13-acetate-induced Epstein-Barr virus (EBV) reactivation occurred in short-term (ST)-cultured EBV-infected epithelial cell lines GT38 and GT39 after their establishment; however, it diminished in the long-term (LT)-cultured cells passaged for more than 2 years from ST-cultured cells. We hypothesized that the EBV reactivation may be related to the EBV DNA copy number in the cells. A higher level of EBV DNA content was detected in ST-cultured cells than in LT-cultured cells by Southern hybridization using an EBV DNA XhoI probe. Fluorescence in situ hybridization using EBV DNA BamHI W fragments showed that ST-cultured cells contained a higher EBV DNA copy number than that of LT-cultured cells. EBV DNA-negative cells were detected in small proportions in LT-cultured cells, but were undetected in ST-cultured cells. These results demonstrate that EBV genomes are not maintained stably in the cell lines, and some of them are lost in continuous passages of the cells. We discuss the mechanisms of reduction of EBV reactivation and EBV DNA in the cell lines.

[In vitro assay method for augmention of anti-Candida activity of murine bone marrow cells by cytokines]

It is important to develop a sensitive assay method for evaluation of immunomodulating candidates including granulocyte-colony stimulating factor (G-CSF) which may augment host defense function against opportunistic infections. Effects of CSFs on anti-Candida activity of bone marrow cells (BMC) obtained from normal or cyclophosphamide-treated immunocompromised mice (CY-mice) were investigated. When BMC from CY-mice were preincubated for 24 hours in the presense of more than 0.005 ng/ml of G-CSF, anti-Candida activity was enhanced at 160 of effector (BMC) to target (C. albicans) ratio, whereas anti-Candida activity of BMC from CY-untreated mice was not changed at concentrations less than only by more than 0.5 ng/ml of G-CSF. Similar enhancement of activity was also observed in the presence of more than 0.05 ng/ml of granulocyte-macrophage colony stimulating factor (GM-CSF) in this assay using BMC from CY-mice. These findings suggest that this in vitro assay method can evaluate the activity of G-CSF and GM-CSF to augment leukocyte's anti-Candida activity.

Differential effect of TPA on cell growth and Epstein-Barr virus reactivation in epithelial cell lines derived from gastric tissues and B cell line Raji

We characterized the cell growth and Epstein-Barr virus (EBV) reactivation for EBV infected epithelial cell lines, GT38, GT39, and GTC-4 using 12-O-tetradecanoylphorbol-13-acetate (TPA). These cell lines grew similarly in liquid medium, and formed colonies in soft agar. The cell growth was inhibited with TPA, dose-dependently in liquid medium. The colony formation was enhanced with low concentrations of TPA, but was inhibited with high concentrations. The latent EBV was reactivated with high concentrations of TPA as shown by the expression of EBV BZLF1 gene product ZEBRA. The effects of TPA on GTC-4 were compared with a Burkitt's lymphoma cell line Raji. The mode of actions of TPA in GTC-4 was different from Raji in terms of cell growth and EBV reactivation. The effective concentrations of TPA for cell growth inhibition and EBV reactivation were higher in Raji than GTC-4. Cell cycle analysis showed that TPA (20 ng/ml) induced cell cycle arrest to Raji but not to GTC-4; however, the rate of trypan blue stained cells increased in the TPA treated GTC-4 but not Raji. These results demonstrated that TPA affects differentially for the stimulation and inhibition of cell growth, and also EBV reactivation depends on TPA concentrations and cell types.

Tumorigenesis of Epstein-Barr virus-positive epithelial cell lines derived from gastric tissues in the SCID mouse

To study the tumorigenesis of Epstein-Barr virus (EBV)-positive epithelial cell lines GT38 and GT39 derived from human gastric tissues, we inoculated these cells under the skin of severe combined immunodeficient (SCID) mice. The development of tumors was observed in each of the mice about 2 months after the inoculation. The tumors were diagnosed with undifferentiated carcinoma by hematoxylin/eosin staining. EBV-encoded small RNA1 was detected in the paraffin-embedded tumor sections. The tumor cells had human chromosome. The circular, but not linear, EBV DNA was detected in the tumors. The molecular sizes of EBV DNA termini were the same as that of the inoculated GT38 or GT39 cells. The expressions of EBV nuclear antigen 2 and latent membrane protein 1 reduced in the tumors. Transcripts of BamHI C and W promoters in latency III were detected in the tumors and the cultured cells in vitro. The tumor cells were passaged from one SCID mouse to other SCID mice and to cultures in vitro. This is the first evidence that the EBV-positive epithelial cell lines produced tumors in the SCID mouse.

Pancreatoblastoma treated by delayed operation after effective chemotherapy

A case of pancreatoblastoma in a 4-year-old girl is presented. She was admitted with an abdominal mass and vomiting in August 1994. Computed tomography scan showed a 10- x 8- x 7-cm mass occupying both the head and body of the pancreas. Serum alpha-fetoprotein (AFP) level was 9,600 ng/mL (normal, <8.3 ng/mL). Results of open biopsy of the tumor showed pancreatoblastoma. Chemotherapy was administered using the new A-1 regimen consisting of cyclophosphamide, etoposide, pirarubicin, and cisplatin. After 3 cycles of chemotherapy, the size of the tumor was reduced to 5 x 4 x 3 cm, the portal vein became patent, and the AFP value decreased to 98.1 ng/mL. Total removal of the tumor was performed leaving the head and tail of the pancreas. Postoperative chemotherapy continued for 2 years. The patient has been disease free for 5 years, and her serum AFP remained within normal levels.

Impaired Kupffer cell function and effect of immunotherapy in obstructive jaundice

BACKGROUND

Obstructive jaundice is frequently associated with septic complications. This study examined the influence of biliary obstruction on bacterial clearance and translocation. The study focused on the phagocytic and killing activities of Kupffer cells and the preventive effect on bacterial translocation of OK-432, which is a hemolytic streptococcal preparation developed as a biological response modifier.

METHODS

To study the mechanism of sepsis in obstructive jaundice, two groups of Wistar rats were examined: rats subjected to common bile duct ligation (CBDL) and rats subjected to a sham operation. Bacterial clearance, organ distribution, hepatic blood flow, and phagocytic function of Kupffer cells were examined. To evaluate the effect of OK-432 on bacterial translocation, rats were divided into three groups: sham operation + phosphate-buffered saline (PBS), CBDL + PBS, and CBDL + OK-432.

RESULTS

In this study, clearance of Escherichia coli. from the peripheral blood in CBDL rats was decreased significantly compared with that in sham-operated rats. Significant decreases in E.coli trapped in the liver and in hepatic blood flow were observed in CBDL rats compared with sham-operated rats. Phagocytic activity and superoxide production of Kupffer cells isolated from CBDL rats were significantly lower than in sham-operated rats. The incidence of bacterial translocation in CBDL rats was increased significantly, and oral administration of OK-432 prevented it.

CONCLUSION

The results suggest that susceptibility to infection in obstructive jaundice is due to impaired phagocytic function of Kupffer cells. Furthermore, obstructive jaundice promotes bacterial translocation, and OK-432 may be useful in preventing this translocation.

Detection of tumor cells in blood using CD45 magnetic cell separation followed by nested mutant allele-specific amplification of p53 and K-ras genes in patients with colorectal cancer

A new method for detecting circulating tumor cells that is based on magnetic-activated cell separation (MACS) and nested mutant allele-specific amplification (nested MASA) was evaluated in patients with colorectal cancer using the p53 and K-ras genes as genetic markers. By negative selection with anti-CD45 monoclonal antibody-conjugated supermagnetic microbeads, the proportion of tumor cells was enriched 9-fold. By the combination of MACS and nested MASA, 10 tumor cells in 10(7) normal peripheral blood mononuclear cells could be detected without false-positives. Using this method, we examined blood taken from the tumor drainage veins of 23 patients with colorectal cancer. Eighty-seven percent (20/23) of primary tumor tissues showed p53 and/or K-ras gene mutations. Forty-five percent (9/20) of patients with p53 and/or K-ras mutations in the primary tumor showed the same mutated genes in the blood samples. There was a significant association between the presence of p53 and K-ras gene mutation in the blood and tumor size, depth of invasion, and venous invasion. Blood gene mutation was detected in 80% (4/5) of samples from patients with synchronous liver metastases. Sixty percent (3/5) of patients with mutant genes in the blood developed asynchronous liver metastases after surgery. The overall survival of patients with p53 and/or K-ras gene mutation-positive findings in blood was significantly shorter than that of patients testing negative on Kaplan-Meier analysis. Our results suggest that the method may be useful for reliable detection of tumor cells circulating in the blood and may help to identify patients at high risk for relapse.

Flat adenoma of the large bowel: re-evaluation with special reference to central depression

PURPOSE

The aim of this study was to re-evaluate the clinicopathologic features of flat adenomas with special reference to the role of central depression found in flat adenomas.

METHODS

Clinicopathologic features, such as grade of atypia by size, site, central depression, coexisting lesions, gender, and family history of cancer, were evaluated in 236 flat adenomas from 183 patients selected retrospectively and prospectively.

RESULTS

Of the 236 flat adenomas, 175 had mild, 33 had moderate, and 28 had severe (i.e., intramucosal carcinoma) atypia. The frequency of severe atypia correlated positively with size. Severe atypia were significantly more frequent in females (21 percent in females and 10 percent in males; P < 0.05). Sixteen percent of flat adenomas in patients with coexisting cancer showed severe atypia, which was significantly more than those without coexisting cancer (P < 0.05). The frequency of multiple flat adenomas in patients with two or more family members with cancer was 53 percent, which was significantly higher than in patients with one or no family members with cancer (P < 0.05). Central depression was observed in 19 percent of flat adenomas. The rate of severe atypia (22 percent) of flat adenomas with central depression was significantly higher than that (9 percent) of flat adenoma without central depression (P < 0.05). Patients who had flat adenomas with central depression had a higher incidence of coexisting cancer and cancer in the family (P < 0.05 and P < 0.01).

CONCLUSION

At colonoscopic examination consideration should be given for the increased potential to become malignant in flat adenomas, especially those with central depression and in patients with a history of malignancy or with a family history of malignancy.

Emergency abdominal surgery in patients aged 80 years and older

The outcome of emergency abdominal surgery in elderly patients remains unsatisfactory. We studied factors contributing to the outcome of abdominal emergency surgery in elderly patients, particularly in those aged 80 years and older. Subjects were 61 patients aged 80 years and older (group A) and 108 patients aged from 65 to 79 years (group B) who underwent emergency abdominal surgery between 1983 and 1997. Complications were significantly higher in group A than in group B, with respiratory failure the most common postoperative complication. Mortality rate within 30 days after surgery was also higher in group A (9.8%) than in group B (3.3%). Complications and mortality did not differ significantly between those with and without preexisting concomitant disease in group A. Systemic inflammatory response syndrome (SIRS) was seen in 35 patients in group A and 50 in group B. Severe complications occurred in 62.5% of group A with preoperative SIRS. Mortality in those with SIRS was significantly higher than those without. SIRS is thus a feasible predictor of poor outcome in patients aged 80 years and older who have emergency abdominal surgery and in those aged from 65 to 79 years. Patients with SIRS should initially receive minimal treatment whenever possible, rather than be overtreated, until their conditions stabilize.

Reperfusion induces sublethal endothelial injury

BACKGROUND

Endothelial cells are pivotal in regulating thrombosis and hemostasis. In this study, we sought to characterize endothelial dysfunction and endothelial cell injury in vitro after hypoxia/reoxygenation.

MATERIALS AND METHODS

Cultured human umbilical vein endothelial cells (ECs) were exposed to 120 min of hypoxia followed by reoxygenation. The release of thrombomodulin (TM) and the production of prostaglandin I2 (PGI2) were measured. Endothelial cell injury in hypoxia/reoxygenation was measured by two assays, the Fura-2 release assay and the 51chromium (51Cr) release assay.

RESULTS

TM release from ECs during normoxic incubation was undetectable, while it was slightly increased during hypoxic incubation. After reoxygenation, the release of TM increased, and it became significantly higher at 120 min after reoxygenation compared with hypoxic incubation. The production of PGI2 significantly decreased during hypoxic incubation and further decreased within 30 min after reoxygenation, but returned to normoxic levels at 120 min after reoxygenation. In the Fura-2 release assay, a rapid and significantly greater release of Fura-2 was observed in hypoxia/reoxygenation compared with hypoxic incubation. In the 51Cr release assay which demonstrates cell death, 51Cr release did not increase in hypoxia/reoxygenation.

CONCLUSIONS

The present study suggests that 120 min of hypoxia/reoxygenation induces endothelial dysfunction of ECs but does not cause cell death.

Productive infection of Epstein-Barr virus (EBV) in EBV-genome-positive epithelial cell lines (GT38 and GT39) derived from gastric tissues

We characterized the expression of Epstein-Barr virus (EBV) on two epithelial cell lines, GT38 and GT39, derived from human gastric tissues. The EBV nuclear antigen (EBNA) was detected in all cells of both cell lines. The EBV immediate-early BZLF 1 protein (ZEBRA), the early antigen diffuse component (EA-D), and one of the EBV envelope proteins (gp350/220) were expressed spontaneously in small proportions in the cells. EBNA 1, EBNA2, latent membrane protein 1, ZEBRA, and EA-D molecules were then observed by Western blotting in the cells. The lytic cycle was enhanced with treatment with 12-O-tetradecanoylphorbol-13-acetate (TPA) or n-butyrate. The virus particles were observed in the TPA treated GT38 cells by electron microscopy. Infectious EBV was detected with the transformation of cord blood lymphocytes and also with the induction of early antigen to Raji cells by the supernatants of both cells lines. A major single and minor multiple fused terminal fragments and a ladder of smaller fragments of the EBV genome were detected with a Xhol probe in both cell lines. These epithelial cells lines and viruses will be useful in studying their association with EBV in gastric epithelial cells.

[Bacterial translocation in multiple organ failure]

Bacterial translocation has been defined as the passage of both viable and nonviable bacteria and their products (e.g., endotoxins) across the intestinal barrier to extraintestinal sites such as the mesenteric lymph nodes, liver, etc. It has been hypothesized that intestinally derived bacteria or endotoxins serve as triggers to initiate, perpetuate, or exacerbate the septic state and thereby promote the development of multiple organ failure (MOF). In various animal studies, bacterial translocation has been associated with mortality and septic complications. Although most data on translocation have been derived from animal studies, convincing evidence has been provided that translocation may occur in humans during various disease states. The question still remains, however, of whether bacterial translocation is an important pathophysiological event in human disease or simply an epiphenomenon of severe disease, since the results are variable. Recent studies have indicated that the gut can produce important amounts of immunoinflammatory factors and that intestinal injury predisposes to distant organ injury even in the absence of detectable bacteria or endotoxins in the portal blood or tissues. This hypothesis may in part explain the inconsistent causal relationship between bacterial translocation and MOF.

Establishment of Epstein-Barr virus-positive human gastric epithelial cell lines

We have established two Epstein-Barr virus (EBV)-positive cell lines, GT38 and GT39, derived from human gastric tissues of two patients bearing gastric carcinoma. Both cell lines were positive for cytokeratin, an epithelial marker, but not for lymphocyte-related markers. Unlike GT39 cell line, GT38 cells lacked the property of contact inhibition. EBV genome was detected in both cell lines. The cell lines were positive for latent membrane protein 1, and EBV-determined nuclear antigen 1 (EBNA1). EBNA2 was also detected in GT38. These cell lines should be useful for studying the interaction of EBV with gastric epithelial cells and its role in gastric carcinogenesis.

[Suppression of anti-Candida activity of human neutrophils by glucose and diminishment of the glucose effect by an amino acid mixture]

Effects of a glucose and amino acid mixture prescribed for parenteral alimentation on anti-Candida activity of neutrophils were examined. Neutrophils obtained from peripheral blood of healthy humans inhibited the growth of Candida albicans in vitro. More than 1.0% of glucose inhibited the anti-Candida activity of the neutrophils in a dose-dependent manner. This glucose effect was reduced by the addition of an amino acid mixture clinically prescribed with a carbohydrate solution (PN-twin) in Japan. The amino acid mixture neutralized the suppression of anti-Candida activity of neutrophils by dexamethasone. These results suggest that an amino acid mixture prescribed in an alimentation solution may play a role as a neutralizer of the suppressive action of glucose for anti-Candida activity of neutrophils in a limited area near the top of a catheter in a blood vessel.

[Experience in administration low dose all-trans retinoic acid for a child with acute promyelocytic leukemia]

Ten year old boy with acute promyelocytic leukemia (APL) was treated with all-trans retinoic acid (ATRA). Immediately after the oral administration of ATRA (nine mg/m2 three times a day), DIC was controlled, and complete remission was achieved at day 39. The patient received ATRA therapy for 47 days, and then followed by conventional chemotherapy. Plasma ATRA level after 90 minutes of drug administration was 84.6 ng/ml. The superoxide generating activity of neutrophils in the bone marrow and peripheral blood was measured by chemiluminescence. The phagocytic function of neutrophils was markedly reduced in the ATRA-induced remission period, and was normal in the chemotherapy-induced remission. APL could be induced complete remission by three divided small doses of ATRA, and the ATRA-induced differentiated neutrophils might have lower phagocytic function.

Recurrent common bile duct stones associated with periampullary duodenal diverticula and calcium bilirubinate stones

We reviewed operative procedures, type of stones, and coexistence of periampullary duodenal diverticula in 115 patients with common bile duct stones who underwent first surgery at our department between 1982 and 1991. Among these patients, 109 underwent choledochotomy with T-tube drainage, 4 underwent side-to-side choledocho-jejunostomy, and 2 had end-to-side choledochojejunostomy. Five patients developed recurrent common bile duct stones (RCS) after surgery. All these patients were older women who had calcium bilirubinate stones in the common duct and coexisting periampullary duodenal diverticula. No patients who underwent end-to-side choledochojejunostomy developed RCS after the initial surgery or reoperation. The results of the present study suggest that both calcium bilirubinate stones and periampullary duodenal diverticula are contributing factors in the development of RCS in patients with common bile duct stones, and that end-to-side choledocho-jejunostomy should be considered for patients with these two factors after the initial common duct exploration.

Characteristics of cytotoxic T lymphocytes directed to influenza virus haemagglutinin elicited by immunization with muramyldipeptide-influenza liposome vaccine

We examined the characterization of the antiviral T lymphocytes elicited by immunization with a novel liposome vaccine (MDP-virosome) constructed with synthetic muramyldipeptide; [6-0-(2-tetradecylhexadecanoyl)-N-acetylmuramyl-L-alanyl-D-isoglutamine] , cholesterol, influenza virus haemagglutinin and neuraminidase. The haemagglutinin glycoprotein first appeared to induce a significant subtype-specific cytotoxic activity through its arrangement on the inner and outer surfaces of the MDP-virosome. Splenocytes of BALB/c mice immunized with the virosome vaccine containing H3 haemagglutinin and N2 neuraminidase from human Hong Kong virus markedly lysed H3N2 virus-infected target cells, but not those infected with virus possessing a different subtype such as H1N1 surface antigens. Exposure of these splenic lymphocytes to virus antigen in vitro further enhanced their cytotoxic activity. The cytotoxic lymphocytes generated by the MDP-virosome vaccine expressed Thy 1 and CD4 antigens on their cell surface, and these activities were restricted by class II histocompatibility gene products. The marked reduction of pulmonary virus titres in infected mice caused by transferred immune spleen cells suggested that the MDP-virosome vaccination is able to protect against influenza virus infection through enhanced cellular immune responses.

Rapid superoxide production by endothelial cells and their injury upon reperfusion

Cultured human umbilical vein endothelial cells (EC) were exposed to hypoxia for various time periods followed by reoxygenation, and production of both O2- and H2O2 by EC was measured using the cytochrome c and scopoletin methods, respectively. Production of significant amounts of O2- was observed as early as 1 min after reoxygenation, reached maximum at 3 min and seemed to decline thereafter. Production of H2O2 was observed slightly later than that of O2-. Endothelial cell injury during hypoxia/reoxygenation was determined by both the trypan blue dye exclusion and chromium release methods. Significant increase of EC injury was detected after reoxygenation by both methods. This injury was significantly inhibited by allopurinol but not by superoxide dismutase or catalase. These results indicate that the production of reactive oxygen metabolites by EC and EC injury occur very rapidly after reoxygenation, which has not been reported, and these should be taken in consideration for the understanding and treatment of the clinical reperfusion injury.

Primary retroperitoneal synovial sarcoma

We present a patient with primary retroperitoneal synovial sarcoma which showed a monophasic fibrous pattern, the fourth such case to be described, and a review of the literature. Synovial sarcoma cells in the present case were stained positive for cytokeratin and epithelial membrane antigen (EMA), of which histology was differentiated from other spindle cell sarcoma with similar light microscopic features. Retroperitoneal synovial sarcoma is usually treated surgically, however only one of 16 cases identified in the literature survived five years after resection. Due to the high fatality rate, physicians should be alerted to the possibility of this disorder in the differential diagnosis of an abdominal mass.

A case of appendiceal cancer metastatic to the stomach with pseudomyxoma peritonei

Appendiceal cancer associated with pseudomyxoma peritonei is a low grade malignancy and its extraperitoneal metastasis is extremely rare. We report a case of gastric metastasis of this tumor in a 76-year-old man. Two metastatic gastric tumors, which appeared after a 1-year interval, were successfully resected endoscopically. The patient was well for more than 3 years after the onset of the disease. To our knowledge, gastric metastasis from appendiceal cancer with pseudomyxoma peritonei has not been previously reported.

Microcomputer-based automatic regulation of extracorporeal circulation: a trial for the application of fuzzy inference

Since its establishment many researchers have been trying to automate the process of extracorporeal circulation (ECC). We developed a preliminary experimental model of an automatic regulatory system for ECC. The purpose of the system was to regulate basic hemodynamic parameters such as pump flow and withdrawal blood volume. It was divided into three main components: data sampling unit, central processing unit, and controlling unit. Based on this model we were able to achieve autoregulation of ECC using minimum configuration; however, the system lacked smoothness. This was partly because it was based on a "static" regulation system which used conditional statements having multiple parameters. In this study, we applied fuzzy logic to the former model to achieve more accurate and reliable regulation. We report experimental results for the new system and compare the data between clinical circulation in 13 infants (mean body weight, 13.32 +/- 5.99 kg) and experimental regulation in 7 mongrel dogs (mean body weight, 11.9 +/- 2.53 kg). The comparative study revealed no statistical difference between the two groups. This result suggests that the automatic regulation of ECC may be an alternative to manual operation by a professional perfusionist in the near future.

Optimal site and amount of splenic tissue for autotransplantation

Clinical and basic studies have documented a high susceptibility to pneumococcal infection in asplenic humans and animals. It has been suggested that autotransplantation of splenic tissue might be a method of providing host resistance when total splenectomy is necessary. However, the effect of splenic autograft has remained controversial. This study was performed to evaluate the most effective site and amount of splenic autograft using rats. Rats were divided into five groups for the purpose of determining the site of splenic autotransplantation: splenectomy, sham operation, implantation into the omental pouch, intraperitoneal implantation, and intramuscular implantation. For determining the amount for autotransplantation, the rats were divided into seven groups: splenectomy, sham operation, and implantations of 25, 50, 100, 200, or 300 mg of splenic tissue. All animals were challenged with Streptococcus pneumoniae type 6, 16 weeks after surgery. Howell-Jolly bodies appeared postsplenectomy, but disappeared in the implanted rats 16 weeks after the operation. Histologically, the implanted tissue was indistinguishable from that of a normal spleen. Pneumococcal clearance from the bloodstream and survival rate were significantly higher in rats implanted in the omental pouch as compared with splenectomized rats. Intraperitoneal and intramuscular implanted rats did not show a significant difference from the splenectomized rats. More than 50% of splenic tissue for autograft showed a significant increase in pneumococcal clearance and survival rate as compared with that of splenectomized rats. It was suggested that the most effective site of autotransplantation is the omental pouch and approximately 50% of the whole spleen would be necessary for prevention from sepsis.

Clinicopathologic features of the flat adenoma

One hundred twenty-eight small flat adenomas (SFAs) were collected from 101 patients, and the clinicopathologic features were investigated. There were 91 adenomas with mild atypia, 20 with moderate atypia, and 17 with severe atypia. SFAs were found more often in males than in females, with a ratio of 3.4:1, and the malignancy rate in females (31.8 percent) was higher than in males (9.3 percent). About 38 percent of the patients had a history of colorectal carcinoma, and 65 percent had a history of colorectal neoplasms. Of 37 patients whose family history was traced, 21 had cancer families. SFAs were prone to be found in patients with a history of colorectal neoplasms and a cancer family. Malignancy rate increased with increasing size. The overall malignancy rate was 13.3 percent, which was considerably higher than that of ordinary small polypoid adenomas (2.8 percent). SFAs were situated more proximally (30.9 percent) than ordinary adenomas; however, there was no relationship between site and malignancy. All the lesions showed tubular adenomas, and there was no villous feature. A central depression was noted in 20 lesions, more frequently in adenomas with higher atypia. All but one adenoma with severe atypia showed a component of lower atypia, supporting the adenoma-carcinoma sequence.

[Human herpesviruses infections (I)--EBV infection and immunity in cancer patients]

Human herpesviruses have been known to be reactivated from latent infection iin immunosuppressed individuals. To assess the immunity, antibodies to human herpesviruses (VZV, HSV, CMV and EBV) were measured in patients with gastrointestinal cancer and normal persons ranging from 40 to 80 in age. CF antibodies to herpesviruses except for EBV were negative in normal persons below the age of 60 and cancer patients aged 60 and over. The CF antibody titer higher than 1:64 occurred only in young cancer patients and older normal persons. The titer of VCA antibody to EBV ranged from 1:40 to 1:160 in more than 80% of normal persons and was higher than 1:640 in less than 7%. The ratio those with antibody negative or below 1:40 increased with the age. In contrast, the titer was higher than 1:320 in 70% of the patients, and the antibody was negative in none of them. In addition, the low titer occurred only in less than 5%. The rate of patients having higher VCA antibody titers increased with age, and the titer was high in more than 50% of patients in the 8th decade. In cancer patients, the higher the VCA antibody titer was, the less number of mature B cells, target cells of EBV, and the B cell functions were observed. This suggests that reactivation of EBV in hosts bearing carcinomas results in a fall of production of the specific antibody.

Adenoma-carcinoma sequence of the large bowel

Fifty-two surgically removed large bowel specimens and 3 colonoscopically removed polyps with mucosal carcinomas were studied. Among 36 frank colorectal carcinomas, six (17%) had a focus of adenomatous remnant. The average size of carcinomas without adenomatous remnant was 56.0 mm and of those with adenomatous remnant was 44.3 mm. Four (67%) of 6 submucosal carcinomas and all of 4 mucosal carcinomas showed an adenomatous remnant. The average size of submucosal carcinomas was 17.7 mm and that of mucosal carcinomas was 16.3 mm. The smaller and less advanced the carcinoma, the more likely it was to show an adenomatous remnant, suggesting that carcinomas arise in adenomas and destroy surviving benign tumour as they grow. Coexisting adenomas were seen in 19 of 46 neoplasm-bearing patients (41%) and 1 of 9 patients (11%) without neoplasms. Average sizes of adenomas with moderate and mild atypia were 13.0 mm and 8.2 mm respectively, which were smaller than the sizes of submucosal and mucosal carcinomas. Although the numbers were small, these findings support the concept of adenoma-carcinoma sequence. Twenty-one flat elevations were collected during the study. Ten were neoplasm (9 adenomas and an early carcinoma), ten were metaplastic polyps and one was a histologically normal mucosal protrusion. The atypism of 10 flat adenomas increased with increasing size, as with ordinary adenomas. As 10 of 55 adenomas (18.2%) were flat adenomas, which are difficult to detect during routine colonoscopic examination, colonoscopists should make every effort to discover flat adenomas, which seem to play an important role in the adenoma-carcinoma sequence.

Primary venous aneurysm of the forearm in a child

A 5 year old girl who presented with two bluish, cystic masses in her right forearm was shown on ultrasonography to have two localized saccular dilatations of the right radial vein. This led to the suspicion of venous aneurysms which was later confirmed by venography. They were finally excised because of the gradual increase in size and pain she had experienced over the previous two months.

Survey of Hanganutziu and Deicher antibodies in operated patients

The appearance of Hanganutziu and Deicher (HD) antibody in the sera of patients suffering from various diseases, including malignancies of some organs and liver disorders, was investigated by enzyme-linked immunosorbent assay using N-glycolylneuraminyl-lactosylceramide (HD3) and 4-O-acetyl-HD3 as the antigenic molecules. More than 25% of sera from patients suffering from malignancies, cholelithiasis and liver cirrhosis had HD antibody, whereas none of 41 sera from healthy persons had HD antibody. The percentage of HD antibody-positive patients was similar in stages I, II and III of gastric cancer and recurrence cases. Antibody titers of the positive patients in each stage were also not different from those in each other stage. These results indicated that HD antigenic expression on cancerous tissue is not dependent on the cancerous malignancy. The HD antibody level was elevated after surgical removal of cancerous tissues in 5 of 6 patients examined, indicating that tumor growth absorbed the serum antibody. Serum antibody against 4-O-acetyl-HD3 was detected independently of HD3 antibody in some cases; however, in most cases, correlation between the two antibody titers was observed.

Prevention of pneumococcal bacteremia by immunization with type 6 pneumococcal capsular polysaccharide vaccine in splenectomized rats

Postsplenectomy sepsis is well recognized and prophylactic vaccination with pneumococcal polysaccharide is recommended. However, the efficacy of vaccination with the polysaccharide in splenectomized individuals is not clear. The effect of type 6 pneumococcal polysaccharide vaccine on the clearance of pneumococci from the bloodstream and lung was studied in splenectomized rats as was survival after intravenous challenge with Streptococcus pneumoniae, serum opsonic activity, and specific antibody titer by ELISA. Rats immunized with type 6 pneumococcal polysaccharide vaccine had significantly increased survival (P less than .05) and clearance of pneumococci from the bloodstream and lung (P less than .05) after intravenous challenge with S. pneumoniae, significantly higher serum opsonic activity (P less than .02), and increased specific IgG and IgM antibody titer to the type 6 polysaccharide compared with controls treated with saline. There was close correlation between IgG antibody titer to type 6 polysaccharide and opsonic activity (r = .95). These results suggest that pneumococcal polysaccharide vaccine is effective for preventing pneumococcal bacteremia in splenectomized hosts.

Role of pili in the pathogenesis of Pseudomonas aeruginosa burn infection

The present study using three isogenic mutants (F+P-, F-P+, F-P-) of Pseudomonas aeruginosa indicates that the presence of pili enhances the virulence of the organisms in experimental P. aeruginosa burn infection of mice. The 50% lethal dose (LD50) value for burned mice inoculated with non-piliated (P-) mutant was at least ten times higher than those inoculated with piliated (P+) bacteria. Meanwhile the LD50 value for burned mice inoculated with non-flagellated (F-) mutant was at least 10(5) times higher than those inoculated with flagellated (F+) bacteria. At 24 hr after inoculation, the bacterial counts in burned skin of mice inoculated with P+ bacteria were ten times higher than those inoculated with P- bacteria; and at 48 hr the bacterial counts became a hundred times higher in the former mice than the latter. At 24 hr after inoculation, P+ bacteria were isolated from blood, liver (F+P+), lung (F+P+), and kidney, while P- bacteria were not present in these tissues. And at 48 hr after inoculation, P+ bacteria were isolated from all tissues, while P- bacteria were isolated from some sites only. These results suggested that pili and flagella each play an important role as virulence factors independently, and that pili-mediated enhancement of virulence of P. aeruginosa was attributed to pili-mediated enhanced colonization of the organisms at the burned skin surfaces.

Role of pili in the adherence of Pseudomonas aeruginosa to mouse epidermal cells

Pili have been demonstrated to be the adhesins of Pseudomonas aeruginosa for mouse epidermal cells. The mechanisms of adhesion of P. aeruginosa to mouse epidermal cells was studied by using four mutants derived from a single strain: flagellated and piliated (F+P+), flagellated and nonpiliated (F+P-), nonflagellated and piliated (F-P+), and nonflagellated and nonpiliated (F-P-) mutants. F+P+ and F-P+ bacteria efficiently adhered to mouse epidermal cells, while F+P- and F-P- bacteria hardly adhered to mouse epidermal cells. The number of F+P+ bacteria that adhered to mouse epidermal cells was almost the same as that of F-P+ bacteria. The number of F+P- bacteria that adhered to mouse epidermal cells was almost the same as that of F-P- bacteria. The adhesion of P+ (F+P+ and F-P+) bacteria was inhibited by antipilus serum, while that of P- (F+P- and F-P-) bacteria was not inhibited by antipilus serum. There were no significant differences between the number of bacteria adhering to mouse epidermal cells isolated from normal skin and those adhering to cells isolated from burned skin. Heating of the mouse epidermal cell suspension had no effect on the adhesion of P. aeruginosa. These results suggest that pili mediate the adhesion of P. aeruginosa to mouse epidermal cells and that P. aeruginosa adheres efficiently to mouse epidermal cells despite the loss of cell viability caused by burning.

The effect of partial splenectomy on experimental pneumococcal bacteremia in an animal model

The effect of total and partial splenectomy on the blood stream clearance of type 23B Streptococcus pneumoniae was studied in chinchillas 2 wk and 2 mo following surgery to determine the amount of splenic tissue necessary for protection against overwhelming sepsis. Significantly more pneumococci were found in the blood of totally splenectomized chinchillas than in the blood of sham-operated animals throughout the 6-hr sampling period after intravenous inoculation of pneumococci. Animals that had two-thirds of their spleen removed demonstrated a significant delay in clearance of pneumococci compared with sham-operated and hemisplenectomized animals. The rate of pneumococcal clearance was similar for the sham-operated and the hemisplenectomized group, and was significantly prolonged but similar among totally splenectomized and two-thirds splenectomized animals. Pneumococcal opsonic activity was reduced only in the sera of totally splenectomized chinchillas 2 mo after surgery. There was no positive relationship between pneumococcal clearance and change in pneumococcal opsonic activity. These results suggest that the impaired clearance of circulating pneumococci in splenectomized animals is due to the loss of splenic reticuloendothelial cells as a mechanical filter, rather than deficient serum opsonic activity. There appears to be a critical splenic mass required for optimal bacterial clearance, and hemisplenectomy may protect against overwhelming postsplenectomy sepsis.

Surgical management of islet-cell adenoma in infancy

Persistent neonatal hypoglycemia is a potentially serious condition which should be recognized promptly, investigated thoroughly, and treated expeditiously. Islet-cell adenoma causing hypoglycemia in infancy is very unusual. Only 23 cases have been reported in the literature. This report documents eight cases of our own and summarizes diagnostic methods, proper medical preparation, and fundamental surgical management. Prompt surgical intervention is emphasized, as this will relieve hypoglycemia and may be important in preventing irreversible central nervous system damage. We are of the opinion that any infant with unremitting hypoglycemia, a high corrected insulin/glucose ratio, and failure to respond to maximum diazoxide therapy will require partial pancreatectomy. Identification of the adenoma at the time of operation is unlikely, and blind pancreatectomy and/or reoperation is not unusual.