A rare case of resection of a mucinous cystic neoplasm originating from the extrahepatic bile duct with cholangioscopic imaging

A 29-year-old woman was admitted to our hospital for examination of obstructive jaundice and an extrahepatic bile duct lesion. Contrast-enhanced computed tomography revealed a 20 mm cystic lesion with a thin external capsule in the common hepatic duct. Cholangioscopy revealed translucent oval masses with capillary vessels attached to the bile duct walls. The surface was mostly smooth yet partially irregular with redness, suggesting that the masses were epithelial neoplasms. Histological findings of cholangioscopy-guided targeted biopsies of the mass showed subepithelial spindle cell proliferation with no atypical epithelium. The patient underwent an extrahepatic bile duct resection to confirm the pathological diagnosis. Immunohistochemistry of surgical specimens revealed that the spindle cells were positive for estrogen and progesterone receptors. Finally, the cystic lesion with ovarian-like stroma was diagnosed as a mucinous cystic neoplasm with low-grade intraepithelial neoplasia. This is the first report of cholangioscopic imaging of a biliary mucinous cyctic neoplasm. Cholangioscopic imaging can be helpful in the differential diagnosis of biliary neoplasms and in the determination of treatment strategies.

A case report of carcinoma of the papilla of Vater associated with a hyperplasia-dysplasia-carcinoma sequence by pancreaticobiliary maljunction

BACKGROUND

Pancreaticobiliary maljunction (PBM) is a known risk factor for biliary tract cancer. However, its association with carcinoma of the papilla of Vater (PVca) remains unknown. We report a case with PVca that was thought to be caused by the hyperplasia-dysplasia-carcinoma sequence, which is considered a mechanism underlying PBM-induced biliary tract cancer.

CASE PRESENTATION

A 70-year-old woman presented with white stool and had a history of cholecystectomy for the diagnosis of a non-dilated biliary tract with PBM. Esophagogastroduodenoscopy revealed a tumor in the papilla of Vater, and PVca was histologically proven by biopsy. We finally diagnosed her with PVca concurrent with non-biliary dilated PBM (cT1aN0M0, cStage IA, according to the Union for International Cancer Control, 8th edition), and subsequently performed subtotal stomach-preserving pancreaticoduodenectomy. Pathological findings of the resected specimen revealed no adenomas and dysplastic and hyperplastic mucosae in the common channel slightly upstream of the main tumor, suggesting a PBM related carcinogenic pathway with hyperplasia-dysplasia-carcinoma sequence. Immunostaining revealed positivity for CEA. CK7 positivity, CK20 negativity, and MUC2 negativity indicated that this PVca was of the pancreatobiliary type. Genetic mutations were exclusively detected in tumors and not in normal tissues, and bile ducts from formalin-fixed paraffin-embedded samples included mutated-ERBB2 (Mutant allele frequency, 81.95%). Moreover, of the cell-free deoxyribonucleic acid (cfDNA) extracted from liquid biopsy mutated-ERBB2 was considered the circulating-tumor deoxyribonucleic acid (ctDNA) of this tumor.

CONCLUSIONS

Herein, we report the first case of PVca with PBM potentially caused by a "hyperplasia-dysplasia-carcinoma sequence" detected using immunostaining and next-generation sequencing. Careful follow-up is required if pancreaticobiliary reflux persists, considering the possible development of PVca.

Reconsidering resectable oncological conditions in pancreatic tail cancer: A multicenter retrospective study on prognostic factors in pancreatic tail cancer after resection (HOPS Pt-01)

BACKGROUND

Pancreatic tail cancer (Pt-PC) is generally considered resectable when metastasis is absent, but doubts persist in clinical practice due to the variability in local tumor extent. We conducted a multicenter retrospective study to comprehensively identify prognostic factors associated with Pt-PC after resection.

METHODS

We enrolled 100 patients that underwent distal pancreatectomy. The optimal combination of factors influencing relapse-free survival (RFS) was determined using the maximum likelihood method (MLM) and corrected Akaike and Bayesian information criteria (AICc and BIC). Prognostic elements were then validated to predict oncological outcomes.

RESULTS

Therapeutic interventions included neoadjuvant treatment in 16 patients and concomitant visceral resection (CVR) in 37 patients; 89 patients achieved R0. Median RFS and OS after surgery were 23.1 and 37.1 months, respectively. AICc/BIC were minimized in the model with ASA-PS (≥2), CA19-9 (≥112 U/mL at baseline, non-normalized postoperatively), need for CVR, 6 pathological items (tumor diameter ≥19.5 mm, histology G1, invasion of the anterior pancreatic border, splenic vein invasion, splenic artery invasion, lymph node metastasis), and completed adjuvant treatment (cAT) for RFS. Regarding the predictive value of these 11 factors, area under the curve was 0.842 for 5-year RFS. Multivariate analysis of these 11 factors showed that predictors of RFS include CVR (hazard ratio, 2.13; 95 % confidence interval, 1.08-4.19; p = 0.028) and cAT (0.38, 0.19-0.76; p = 0.006).

CONCLUSIONS

The MLM identified certain Pt-PC cases warranting consideration beyond resectable during clinical management. Particular attention should be paid to conditions requiring CVR, even though immortal time bias remains unresolved with adjuvant treatment.

Artificial Conditioner for Stored Organs

We have developed an artificial organ conditioning system in order not only to condition but also evaluate the viability for transplant graft of kidneys which have been stored for a long time and damaged by warm ischaemia following cardiac arrest. The conditioning system consisted of an artificial lung, a roller pump, an organ chamber and perfusate. The perfusate was prepared with electrolytes, fluorocarbon, amino acid, glucose, an oxygen scavenger and so on. Conditioning was performed by continuous perfusion under mild hypothermia at 24° C. Mildly damaged kidneys (0 and 30 minutes warm ischaemia rabbit kidneys) were well conditioned but severely damaged kidneys failed to produce urination. Our device successfully exposed the viability of stored kidneys and the successful conditioning of damaged kidneys due to warm ischaemia avoiding transplantation. By establishing our method, the harvesting of kidneys following cardiac arrest will be feasible.

Reduction of EDA (+) fibronectin and its clinical importance on cryofiltration

Cryofiltration (CRYO) removes cryogel, which is a combination of fibrinogen (Fbg) and fibronectin (FN), containing pathological substances. The purpose of this study was to measure cryogel EDA(+) FN and study the relationship between EDA(+) FN and clinical symptoms in patients with rheumatoid arthritis, SLE and polymyositis. Cryogel contains 51 times more EDA(+) FN than plasma. The patients with rheumatoid arthritis showed a high level of EDA(+) FN in their plasma, and the EDA(+) FN level in plasma corresponded with changes in joint pain. We calculated the clearance level at several points in cryofiltration, and the reduction enabled us to evaluate the CRYO device. The EDA(+) FN clearance was 23.3 ± 6.4 ml/min, the pFN clearance 16.5 ± 4.1 ml/min, and the Fbg clearance 22.9 ± 5.7 ml/min. As the plasma flow in cryofiltration was 30 ml/min, a clearance of EDA(+) FN and Fbg, approximately 23 ml/min, was obviously high. The study of the plasma level change of EDA(+) FN during cryofiltration revealed a temporary elevation. These results suggest that the EDA(+) FN was most efficiently reduced by cryofiltration, would become a good indicator on plasmapheresis, and might move from other tissues into the blood during cryofiltration.

Hypoxia augments MHC class I antigen presentation via facilitation of ERO1-α-mediated oxidative folding in murine tumor cells

To establish an effective cancer immunotherapy, it is crucial that cancer cells present a cancer-specific antigen in a hypoxic area, a hallmark of the tumor microenvironment. Here, we show the impact of hypoxia on MHC class I antigen presentation in vitro and in vivo in murine tumors. Activation of antigen-specific CTLs by tumor cells that had been pre-incubated under a condition of hypoxia was enhanced compared with that by tumor cells pre-incubated under a condition of normoxia. Cell surface expression of MHC class I-peptide complex on the tumor cells was increased under a condition of hypoxia, thereby leading to higher susceptibility to specific CTLs. We show that the hypoxia-inducible ER-resident oxidase ERO1-α plays an important role in the hypoxia-induced augmentation of MHC class I-peptide complex expression. ERO1-α facilitated oxidative folding of MHC class I heavy chains, thereby resulting in the augmentation of cell surface expression of MHC class I-peptide complex under hypoxic conditions. These results suggest that since the expression of MHC class I-peptide complex is augmented in a hypoxic tumor microenvironment, strategies for inhibiting the function of regulatory T cells and myeloid-derived suppressor cells and/or immunotherapy with immune checkpoint inhibitors are promising for improving cancer immunotherapy.

Cancer-associated oxidoreductase ERO1-α drives the production of VEGF via oxidative protein folding and regulating the mRNA level

Background:

Endoplasmic reticulum disulfide oxidase 1-α (ERO1-α) is an oxidase that exists in the endoplasmic reticulum and has a role in the formation of disulfide bonds of secreted proteins and cell-surface proteins. Recently, we reported that ERO1-α is present in high levels in various types of tumours, and that ERO1-α is a novel factor of poor prognosis. However, how ERO1-α affects a tumour in vivo and why patients who have a tumour with a high expression level of ERO1-α have a poor prognosis are still unknown. Therefore, to clarify the mechanism, we investigated the effect of ERO1-α on a tumour from the point of view of angiogenesis.

Methods:

The effect of ERO1-α on tumour growth and angiogenesis was analysed by using non-obese diabetic-severe combined immunodeficient mice. The production of vascular endothelial growth factor (VEGF) in MDA-MB-231 cells with ERO1-α- overexpression or with ERO1-α knockdown was measured. The role of ERO1-α on VEGF expression was investigated. In triple-negative breast cancer cases, the relationship between expression of ERO1-α and angiogenesis was analysed.

Results:

We found that the expression of ERO1-α promoted tumour growth in a mouse study and angiogenesis. The effects of ERO1-α on angiogenesis were mediated via oxidative protein folding of VEGF and enhancement of VEGF mRNA expression by using MDA-MB-231. In triple-negative breast cancer cases, the expression of ERO1-α related to the number of the blood vessel. Furthermore, we found that ERO1-α was a poor prognosis factor in triple-negative breast cancer.

Conclusions:

Our study has established a novel link between expression of ERO1-α and secretion of VEGF, providing new evidence for the effectiveness of ERO1-α-targeted therapy in patients with ERO1-α-expressed cancer.

Heat shock protein 90 associates with Toll-like receptors 7/9 and mediates self-nucleic acid recognition in SLE

Systemic lupus erythematosus (SLE) is a prototype systemic autoimmune disease, and disease activity is associated with serum IFN-α level. Plasmacytoid dendritic cells (pDCs) sense microbial as well as self-nucleic acids by TLRs 7 and 9 and produce a large amount of IFN-α. Here, we show that heat shock protein 90 (Hsp90) associates with and delivers TLR7/9 from the ER to early endosomes for ligand recognition. Inhibition of Hsp90 by various approaches including the use of Hsp90 inhibitor, a geldanamycin derivative, suppressed the Hsp90 association with TLR7/9, which resulted in inhibition of IFN-α production, leading to improvement of SLE symptoms in mice. Notably, we observed that serum Hsp90 is clearly increased in patients with active SLE compared with that in patients with inactive disease. Furthermore, we demonstrated that serum Hsp90 detected in SLE patients binds to self-DNA and/or anti-DNA Ab, thus leading to stimulation of pDCs to produce IFN-α. Our data demonstrate that Hsp90 plays a crucial role in the pathogenesis of SLE and that an Hsp90 inhibitor will therefore provide a new therapeutic approach to SLE and other nucleic acid-related autoimmune diseases.

Cancer-Associated Oxidase ERO1-α Regulates the Expression of MHC Class I Molecule via Oxidative Folding

ERO1-α is an oxidizing enzyme that exists in the endoplasmic reticulum and is induced under hypoxia. It reoxidizes the reduced form of protein disulfide isomerase that has oxidized target proteins. We found that ERO1-α is overexpressed in a variety of tumor types. MHC class I H chain (HC) has two disulfide bonds in the α2 and α3 domains. MHC class I HC folding is linked to the assembly of MHC class I molecules because only fully disulfide-bonded class I HCs efficiently assemble with β2-microglobulin. In this study, we show that ERO1-α associates with protein disulfide isomerase, calnexin, and immature MHC class I before being incorporated into the TAP-1-associated peptide-loading complex. Importantly, ERO1-α regulates the redox state as well as cell surface expression of MHC class I, leading to alteration of susceptibility by CD8(+) T cells. Similarly, the ERO1-α expression within cancer cells was associated with the expression level of MHC class I in colon cancer tissues. Thus, the cancer-associated ERO1-α regulates the expression of the MHC class I molecule via oxidative folding.

Clinical feasibility of laparoscopic lateral pelvic lymph node dissection following total mesorectal excision for advanced rectal cancer

PURPOSE

To evaluate the technical feasibility, safety and oncological outcomes of laparoscopic lateral pelvic lymph node dissection in patients with advanced low rectal cancer.

METHODS

Laparoscopic lateral pelvic lymph node dissection was performed in 18 patients from November 2009 to September 2012. The data regarding the patient demographics, surgical outcomes and short-term oncological outcomes were analyzed.

RESULTS

In all 18 patients, the procedures were completed without conversion to open surgery. The mean length of the operation was 603.7 min (473-746 min). The mean number of harvested lateral pelvic lymph nodes was 16.9 (7-27), and five patients (27.8 %) had lymph node metastases. The postoperative mortality and morbidity rates were 0 and 16.7 %, respectively. Three patients developed Grade 2 urinary retention. No local recurrence had developed after a mean follow-up period of 23.6 months.

CONCLUSION

Laparoscopic lateral pelvic lymph node dissection is technically feasible, safe and oncologically acceptable within the limitations of the short-term follow-up period.

Human endoplasmic reticulum oxidoreductin 1-α is a novel predictor for poor prognosis of breast cancer

Human endoplasmic reticulum oxidoreductin 1-α (hERO1-α) is an oxidizing enzyme that exists in the endoplasmic reticulum and its expression is augmented under hypoxia. It regulates a redox state of various kinds of protein through reoxidation of "client" protein disulfide isomerase. Interestingly, although the expression of hERO1-α in normal tissues was comparatively limited, various types of cancer cells expressed it in large amounts. Therefore, we examined the role of ERO1-α in tumor growth using murine breast cancer line 4T1 and found that knockdown of murine ERO1-α inhibited in vivo tumor growth and decreased lung metastasis compared with wild-type 4T1. Moreover, we investigated the relationship between expression of hERO1-α and prognosis in breast cancer patients. Seventy-one patients with breast cancer who underwent surgery between 2005 and 2006 in Sapporo Medical University Hospital (Sapporo, Japan) were analyzed in this study. Significant differences were found between the hERO1-α-positive group (n = 33) and hERO1-α-negative group (n = 38) in nuclear grade (P < 0.001) and intrinsic subtype (P = 0.021) in univariate analysis. More importantly, in multivariate analysis of disease-free survival by Cox regression, expression of hERO1-α was the only independent prognosis factor (P = 0.035). Finally, in univariate survival analysis, patients positive for hERO1-α had significantly shorter disease-free survival and overall survival than those patients negative for hERO1-α. These findings indicate that the expression of hERO1-α in cancer cells is associated with poorer prognosis and thus can be a prognostic factor for patients with breast cancer.

[Human endoplasmic reticulum oxidoreductin 1-like α regulates immune response of cancer cells via modulation of major histocompatibility complex class I expression and oxidation]

The protein human endoplasmic reticulum oxidoreductin 1-like α(hERO1-L α) is a hypoxia-inducible endoplasmic reticulum resident oxidase that regulates the redox state of various proteins via protein disulfide isomerase. The major histocompatibility complex(MHC) class I molecule contains intramolecular disulfide bonds. hERO1-L α is expressed within normoxic cells at very low levels, but may be induced in hypoxic cells such as tumor cells in response to low oxygen availability. We therefore examined whether hERO1-L α affects the oxidation state and expression level of MHC class I in the colon cancer cell line SW480. We generated SW480 cells in which hERO1-L α was overexpressed or knocked down. The surface expression of MHC class I molecule was upregulated in the hERO1-L α-overexpressing SW480 cells and downregulated in the hERO1-L α-knockdown SW480 cells. Moreover, the oxidized form of MHC class I was increased in the hERO1-L α-overexpressing SW480 cells, and the hERO1-L α-knockdown SW480 cells exhibited an impaired response to cytotoxic T lymphocytes. These data suggest that hERO1-L α regulates immune response via modulation of MHC class I expression and oxidation, and that hERO1-L α may act as a new predictive factor for cancer immunotherapy.

Heat-shock proteins as endogenous ligands building a bridge between innate and adaptive immunity

There has been growing evidence that heat-shock protein (HSP) functions as an endogenous immunomodulator for innate and adaptive immune responses. Since HSPs inherently act as chaperones within cells, passive release (e.g., by cell necrosis) and active release (including release by secretion in the form of an exosome) have been suggested as mechanisms of HSP release into the extracellular milieu. Such extracellular HSPs have been shown to be activators of innate immune responses through Toll-like receptors. However, it has also been suggested that HSPs augment the ability of associated innate ligands such as lipopolysaccharides to stimulate cytokine production and dendritic cell maturation. More interestingly, a recent study has demonstrated that innate immune responses elicited by danger signals were regulated spatiotemporally and that can be manipulated by HSPs, thereby controlling immune responses. We will discuss how spatiotemporal regulation of HSP-chaperoned molecules within antigen-presenting cells affects adaptive immunity via antigen cross-presentation and innate immune responses. Precise analysis of HSP biology should lead to the establishment of effective HSP-based immunotherapy.

Prognostic impact of preoperative the branched-chain amino acid to the tyrosine ratio in hepatocellular carcinoma patients after initial hepatectomy

INTRODUCTION

The branched-chain amino acid/tyrosine ratio (BTR) reflects the amino acid balance and the severity of liver disease. The aim of the present study was to determine the relationship between BTR and liver function in patients with hepatocellular carcinoma (HCC). Furthermore, we evaluated the clinical usefulness of BTR as a prognostic indicator of disease-free and overall patient survival after initial hepatectomy.

METHODS

Between January 2004 and December 2008, 105 consecutive HCC patients who underwent initial hepatectomy were enrolled in this study. The correlation between BTR and preoperative liver functional indicators was evaluated. The cutoff levels of BTR for 2-year survival prediction were evaluated using a dot blot diagram. The patients were divided into high BTR (4.5 or higher) and low BTR (4.4 or lower) groups and these were compared in terms of clinical variables such as liver functional indicators, operative variables, and tumor characteristics.

RESULTS

The preoperative BTR level decreased according to the severity of liver disease. BTR was correlated with the albumin, bilirubin, and prealbumin levels, as well as the prothrombin time. Although the preoperative liver function was significantly different between the high BTR and low BTR groups, the operative variables and tumor-related variables were not found to be significantly different. Postoperative complications in the high BTR group were significantly less frequent than in the low BTR group (p = 0.003). Disease-free and overall patient survival in the high BTR group were significantly longer than in the low BTR group (p < 0.001 and p = 0.021, respectively).

CONCLUSIONS

BTR reflected the pathological liver background with a high correlation to the other liver functional indicators. BTR is thus considered to be a useful marker to predict postoperative complications, disease-free survival, and overall survival of HCC patients after initial hepatectomy. It is, therefore, a useful indicator of liver function and a predictor for the risk of cancer recurrence and overall survival in HCC patients.

Successful ex vivo normothermic liver perfusion with purely artificial products using artificial blood

We tried to make an ex vivo functioning liver with an artificial perfusate that consisted of artificial blood in the pig liver. A liver graft from a female pig weighing 20 kg was harvested in the usual manner. The perfusion solution consisted of artificial blood, L-15 medium, distilled water, bovine serum albumin, NaHCO3, NaOH, KCl, human regular insulin, 50% glucose solution, and dexamethasone. The isolated liver was perfused with this oxygenated perfusate through the portal vein at a rate of 300 ml/min for 9 hours. Seven livers were perfused for 9 hours in this system. Five of the livers showed mean oxygen consumption of over 8 ml-O2/min during perfusion. Histological findings showed that the hepatic architecture was almost completely preserved and numerous hepatocytes exhibited PAS-positive cytoplasmic glycogen deposits in these livers. These observations indicate that we have succeeded in developing an ex vivo functioning liver with an artificial perfusate employing artificial blood.

Experimental study using heparin-immobilized adsorbent of EDA(+)fibronectin

EDA(+)fibronectin, which might participate in the pathogenesis and/or progress of immune diseases, is efficiently removed from plasma by cryofiltration; however, cryofiltration removes not only EDA(+)fibronectin, but also other proteins. We thus developed a new adsorbent by using its high affinity with heparin. The purpose of this study was to evaluate the efficacy of the adsorbent of EDA(+)fibronectin (OHC-20) in experimental arthritis. The experimental arthritis was induced by injection of 0.5 mg of Mycobacterium butyricum in Lewis rats. Rats were divided into 4 groups; 1 nontreatment group, and 3 treatment groups. Adsorption therapy in treatment groups was performed three times: on Days 1, 3, and 5 in Group A; Days 7, 9, and 11 in Group B; and Days 13, 15, and 17 in Group C. The walking postures of rats improved from dragging to walking on tiptoe, and the increase of hind-foot volume was suppressed in Groups B and C. We conclude that heparin-immobilized adsorbent might be promising for immune diseases.

A chylous cyst of the mesentery: report of a case

A case is presented of an adult chylous cyst of the mesentery that was preoperatively diagnosed to be a pancreatic cystadenoma. A 66-year-old asymptomatic male was followed up for 15 months under the diagnosis of a benign pancreatic cyst. On October 1997, computed tomography showed a 45 x 40 mm cystic mass in the upper abdomen which came in contact with the pancreas. Endoscopic ultrasonography revealed a multilocular mass with a 7 x 4 mm elevated lesion. Endoscopic retrograde cholangiopancreatography and magnetic resonance cholangiopancreatography revealed the cystic mass to be unrelated to the pancreatic duct. The preoperative diagnosis was a pancreatic cystadenoma or cystadenocarcinoma. A laparotomy showed a 50 x 40 mm cystic mass containing chylous fluid, that arose from the mesentery of the upper part of the jejunum. The pathological diagnosis was a chylous cyst of the mesentery. The preoperative diagnosis in this case was very difficult because the chylous cyst appeared to be attached to the pancreas and this phenomenon is considered to be extremely rare.

Changes of plasma fibronectin in patients treated with cryofiltration for an extended period

The purpose of this study was to evaluate correlations between extra domain A fibronectin (EDA[+]FN) in plasma and the clinical course in cryofiltration for an extended period. Two patients with systemic lupus erythematosus (SLE), 1 with aortitis syndrome, 1 with ankylosis spondylitis, 1 with polymyositis, 1 with rheumatoid arthritis, and 1 with chronic rejection of a kidney graft, were regularly treated with cryofiltration for more than 3 years. The average level of EDA(+)FN in each year did not show significant change in clinically stable patients with aortitis syndrome, polymyositis, and SLE. In the patient with ankylosis spondylitis, the average level of EDA(+)FN in each year elevated, so cryofiltration was performed frequently. On the other hand, cryofiltration could not attenuate the progression in the juvenile rheumatoid arthritis patient. In the patient with chronic rejection of a kidney graft, kidney function without hemodialysis could be prolonged for 33 months by cryofiltration. The average level of EDA(+)FN elevated as the graft function got worse. Changes of average level of EDA(+)FN in plasma corresponded with changes in the clinical courses of patients with autoimmune disease and chronic rejection of a kidney graft. The EDA(+)FN level might give prognostic information and determine the interval of cryofiltration.

New technique of leukocytapheresis by the use of nonwoven polyester fiber filter for inflammatory bowel disease

Leukocytapheresis (LCAP) is widely used for the treatment of immunological diseases. We studied a new treatment of LCAP using a nonwoven polyester fiber filter. In a basic study, 30-70% of leukocytes were removed. Also, 30-68% of the leukocyte subsets were removed. Sixteen inflammatory bowel disease (IBD) patients, mainly with ulcerative colitis (UC), were treated by this method. Their cytokine activity was normalized in the filter and in the peripheral blood. Eleven of 12 patients with UC were induced to remission. Four patients with Crohn's disease (CD) exhibited improvement. The LCAP using a nonwoven polyester fiber filter was very efficient for treating the patients with IBD. Also, it will be a very useful treatment for immunological diseases and extracorporeal immunomodulation.

Cryofiltration apheresis for major ABO-incompatible kidney transplantation

The barrier of ABO-incompatible kidney transplantation is the presence of anti-A and anti-B antibodies in the recipient's circulating blood. Double filtration plasmapheresis (DFPP) is usually used to eliminate those antibodies. We tried cryofiltration apheresis (CRYO) in 2 recipients. Patient 1 was a 45-year-old male with B, Rh(+). The titers of IgM anti-A antibody were only reduced from x64 to x32 by the end of 3 sessions of standard CRYO. Renal allografting was not performed. Case 2 was a 29-year-old male with B, Rh(+). CRYO was introduced for 3 sessions. The initial IgM and IgG titers were x128 and negative, respectively. The standard CRYO system was modified by temperature, treated volume, and filter pore size. The IgM anti-A antibody titer was markedly reduced to x2 after the final session of CRYO. The donor was a 56-year-old father with A, Rh(+). Tacrolimus, azathioprine, methylprednisolone, and antilymphocyte globulin were used as the introductory immunosuppression therapy.

Reduction of EDA(+) fibronectin and its clinical importance on cryofiltration

Cryofiltration (CRYO) removes cryogel, which is a combination of fibrinogen (Fbg) and fibronectin (FN), containing pathological substances. The purpose of this study was to measure cryogel EDA(+) FN and study the relationship between EDA(+) FN and clinical symptoms in patients with rheumatoid arthritis, SLE and polymyositis. Cryogel contains 51 times more EDA(+) FN than plasma. The patients with rheumatoid arthritis showed a high level of EDA(+) FN in their plasma, and the EDA(+) FN level in plasma corresponded with changes in joint pain. We calculated the clearance level at several points in cryofiltration, and the reduction enabled us to evaluate the CRYO device. The EDA(+) FN clearance was 23.3 +/- 6.4 ml/min, the pFN clearance 16.5 +/- 4.1 ml/min, and the Fbg clearance 22.9 +/- 5.7 ml/min. As the plasma flow in cryofiltration was 30 ml/min, a clearance of EDA(+) FN and Fbg, approximately 23 ml/min, was obviously high. The study of the plasma level change of EDA(+) FN during cryofiltration revealed a temporary elevation. These results suggest that the EDA(+) FN was most efficiently reduced by cryofiltration, would become a good indicator on plasmapheresis, and might move from other tissues into the blood during cryofiltration.

Artificial conditioner for stored organs

We have developed an artificial organ conditioning system in order not only to condition but also evaluate the viability for transplant graft of kidneys which have been stored for a long time and damaged by warm ischaemia following cardiac arrest. The conditioning system consisted of an artificial lung, a roller pump, an organ chamber and perfusate. The perfusate was prepared with electrolytes, fluorocarbon, amino acid, glucose, an oxygen scavenger and so on. Conditioning was performed by continuous perfusion under mild hypothermia at 24 degrees C. Mildly damaged kidneys (0 and 30 minutes warm ischaemia rabbit kidneys) were well conditioned but severely damaged kidneys failed to produce urination. Our device successfully exposed the viability of stored kidneys and the successful conditioning of damaged kidneys due to warm ischaemia avoiding transplantation. By establishing our method, the harvesting of kidneys following cardiac arrest will be feasible.

[An autopsy case of pulmonary metastasis of cholangiocellular carcinoma associated with marked fibrotic change of the lungs]

An autopsy case of pulmonary metastasis of cholangiocellular carcinoma is presented. A 44-year-old woman was admitted to our hospital because of dyspnea, general fatigue and a sense of abdominal fullness on February 5, 1990. In November 1986, at an other hospital, she had been diagnosed as having diffuse metastatic lung tumor and multiple bone metastases, by transbronchial lung biopsy and other examinations. During the clinical course, she was not received chest irradiation and chemotherapy which induced fibrotic change of lungs. Chest X-ray film on December 21, 1986 showed diffuse nodular shadows in both lung fields. Chest X-ray film on February 4, 1990 showed diffuse reticular shadows with marked shrinkage of lung fields. She died two months after admission. The primary site of the carcinoma was not determined clinically, but was revealed by autopsy to be cholangiocellular carcinoma of the liver, with generalized metastasis. Microscopic findings of the autopsied lung showed markedly increased connective tissue around bronchi and blood vessels, in areas where microtubular adenocarcinoma was scattered. This is a very rare case of pulmonary metastasis of cholangiocellular carcinoma, associated with marked fibrotic change of the lungs during about 3.5 years. To our knowledge, this is the first reported case.

[Cytotoxic effect of anticancer drug combined with anti-AFP antibody on human hepatoma cell in vitro]

The cytotoxic effect of the anticancer drug, Daunorubicin, combined with the anti human AFP horse antibody (Conjugate) on AFP-producing cells and non producing cells was studied in vitro. No different cytotoxic effects between the conjugate and the anticancer drug alone were observed on non-AFP-producing cells. On the other hand, the conjugate had a much stronger cytotoxic effect than the anticancer drug alone against AFP-producing cells when it was incubated for 24 hours, 5 x 10(-1) micrograms/ml as an anticancer concentration. The cytotoxicity of the conjugate is much stronger than of the comcrued effect of the anticancer drug and the anti AFP antibody (individually). The amount of AFP antibody used was very small. Therefore, the effect of the anticancer drug plus the small amount of AFP antibody was almost the same as the effect of anticancer drug alone. Under these conditions melting of nuclear material (cell death) was remarkable morphologically, and the intracellular anticancer concentration of the conjugate was seven times higher than that of the anticancer drug alone (p less than 0.05). In conclusion, the conjugate has more cytotoxic effect than the anticancer drug alone against AFP-producing hepatoma cells in optimal conditions.

Deacetylravidomycin N-oxide, a new antibiotic. Taxonomy and fermentation of the producing organism and isolation, structure and biological properties of the antibiotic

Streptomyces ravidus S50905 was found to produce a new antibiotic, deacetylravidomycin N-oxide, together with ravidomycin and deacetylravidomycin in a culture medium containing sodium anthraquinone-beta-sulfonate. The structure of this new compound was determined from NMR and mass spectrometric data, and further confirmed by chemical synthesis from deacetylravidomycin. Deacetylravidomycin N-oxide was antitumor active against P388 leukemia and Meth A fibrosarcoma in a wide range of doses, and considerably less toxic than deacetylravidomycin. Its antibacterial activity was less potent than deacetylravidomycin. Ravidomycin N-oxide was also synthesized from ravidomycin and its biological properties were tested.

[The significance of blood coagulation test in fulminant hepatic failure]

We treated 12 cases of fulminant hepatic failure with plasma exchange, cryofiltration and hemodialysis. Five cases were survived and 7 cases died. The liver volume measured by volus CT on admission was about 1106 ml in survived cases, and was about 457 ml in death cases. In cases which liver volume was under 600 ml, these prognoses were miserable. AT-III, PT and HPT activities were well correlated with liver volume (r = 0.85) and these activities were good indicator to treat the fulminant hepatic failure. The measurement of FBG and APTT were also useful for the estimation of the prognosis. But they were not becoming of indicator to treatment. We have no expectation to prognosis of the cases which PT, HPT and AT-III were under 15%, 10%, and 25%, respectively.

Azinomycins A and B, new antitumor antibiotics. III. Antitumor activity

Azinomycins A and B, isolated from the culture broth of Streptomyces griseofuscus S 42227, were examined for antitumor activities against P388 leukemia, P815 mastocytoma, B-16 melanoma, Ehrlich carcinoma, Lewis lung carcinoma and Meth A fibrosarcoma. Azinomycin B was markedly effective against the intraperitoneally inoculated tumors such as P388 leukemia, B-16 melanoma and Ehrlich carcinoma. The intraperitoneal administration of azinomycin B showed 57% survivors for 45 days and 193% ILS against P388 leukemia. For Ehrlich carcinoma, azinomycin B gave 161% ILS and 63% survivors for 45 days, but solid tumors such as Lewis lung carcinoma and Meth A fibrosarcoma were not susceptible to repeated injection of this substance. Azinomycin A was somewhat less effective than azinomycin B for the tumor systems tested.

Effect of anti-alpha-fetoprotein serum on human hepatoblastoma

There is no definitive treatment of hepatoblastoma. Except for radical resection, the prognosis of unresectable cases remains pessimistic. Therefore, the development of new anticancer drugs for this tumor is urgently needed. Using the human hepatoblastoma cell line (c-HB-3) we demonstrated that horse anti-alpha-fetoprotein containing serum suppressed proliferation of the hepatoblastoma cells. This effect was dependent on the duration of exposure and the concentration of anti-alpha-fetoprotein serum.