Bicarbonate in Arteries Measured Preoperatively for Cadaveric Single-lung Transplantation is Related to Intraoperative Extra-Corporeal Membrane Oxygenation Use: A Retrospective Preliminary Study

Background

There are no known predictors of extracorporeal membrane oxygenation (ECMO) induction for single lung transplantation.

Objective

The purpose of the present study was to clarify the relationship between variables and ECMO requirements in single lung transplantation.

Methods

This study included adult patients who underwent cadaveric single lung transplantation between 2010 and 2019. After general anesthesia, the transplanted lungs were ventilated in all cases. The analysis included 38 patients in the ECMO required (RQ) group and 12 patients in the ECMO non-required (FR) group. Comparisons were made between the two groups for data affecting ECMO implementation, and data that were significantly different were subjected to multivariate analysis.

Results

Prior to anesthesia, the bicarbonate (HCO3-) value of the FR group was lower than that of the RQ group (24.6±2.7 vs. 29.7±5.3 mmol/L, p=0.005). Multivariate analysis showed that the cut-off bicarbonate value was 29.6. The area under the receiver operating characteristic curve (AUROC) of the model was 0.869 (R2: 0.331), with a sensitivity of 79% and a specificity of 88%. The odds ratio was 1.63 for every unit increase in the bicarbonate value (95%CI: 1.11-2.39, p<0.001). Further, the FR group had higher arterial blood pressure (mean: 79.0±11.5 vs. 68.9±8.3 mmHg, p=0.030), less blood loss (432±385 vs. 1,623±1,997 g, p<0.001), shorter operation time (417±44 vs. 543±111 min, p<0.001), and shorter ICU stay (11±9 vs. 25±38 days, p=0.039).

Conclusion

Preoperative evaluation of bicarbonate could predict the need for ECMO for single lung transplantation.

Sequence analysis of ABO and its homologues is valid for species identification

BACKGROUND

ABO and its paralogues, such as A3GALT2 and GGTA1, encoding α1,3-Gal(NAc) transferases, belong to the glycosyltransferase 6 (GT6) gene family. We have developed an alternative method for the identification of species based on sequence variations within the GT6 gene family, which is applicable to degraded DNA.

METHODS/MATERIALS

DNA samples prepared from control mammalian species, together with an unknown sample, were polymerase chain reaction (PCR)-amplified using one universal primer pair targeting the sequences in the last coding exons of the GT6 gene family, yielding 141-bp products derived from those multiple loci. After cloning, sequence determination and Basic Local Alignment Search Tool analysis, phylogenetic trees were constructed.

RESULTS

Comparison of the sequences obtained with those references showed good concordance with each of the starting species of mammals. This system was able to identify 'mouse' or 'rodent' as the origin of the unknown sample.

CONCLUSION

For the identification of species, genotyping of ABO and its homologues would be applicable for the analysis of degraded DNA samples. Although the method employed in this study is likely valid for mammals, it would not be suitable for birds, fish and reptiles. It may be possible to improve the present method for use with other species by employing an alternative universal primer set.

ABO alleles are linked with haplotypes of an erythroid cell-specific regulatory element in intron 1 with a few exceptions attributable to genetic recombination

Recent investigation of transcriptional regulation of the ABO genes has identified a candidate erythroid cell-specific regulatory element, named the +5·8-kb site, in the first intron of ABO. Six haplotypes of the site have been reported previously. The present genetic population study demonstrated that each haplotype was mostly linked with specific ABO alleles with a few exceptions, possibly as a result of hybrid formation between common ABO alleles. Thus, investigation of these haplotypes could provide a clue to further elucidation of ABO alleles.

Blood group B gene is barely expressed in in vitro erythroid culture of Bm-derived CD34+ cells without an erythroid cell-specific regulatory element

BACKGROUND AND OBJECTIVES

Previously, a weak phenotype Am or Bm was assumed to be caused by a reduction of A or B gene expression in bone marrow cells, but not in mucus-secreting cells. However, ABO expression has not been examined in erythroid progenitor cells of Am or Bm individuals.

MATERIALS AND METHODS

We carried out in vitro erythroid differentiation of CD34(+) cells from peripheral blood of a Bm individual harbouring a 3.0-kb deletion including an erythroid cell-specific regulatory element, named the +5.8-kb site, in intron 1 of the human ABO blood group gene.

RESULTS

During the in vitro differentiation of CD34(+) cells from this Bm individual into erythroid cells, B-antigens were not detectable on the cultured cells by flow cytometric analysis, and allele-specific RT-PCR consistently detected the transcripts from the O allele, but not from the B allele. Moreover, chromatin immunoprecipitation assay demonstrated that both RUNX1 and GATA-2 or GATA-1 were bound to the +5.8-kb site in cultured erythroid cells expressing ABO.

CONCLUSION

It is likely that the +5.8-kb site enhances transcription from the ABO promoter in erythroid cells through binding of RUNX1 and GATA-2 or GATA-1.

Deletion of the RUNX1 binding site in the erythroid cell-specific regulatory element of the ABO gene in two individuals with the Am phenotype

BACKGROUND AND OBJECTIVES

An erythroid cell-specific regulatory element, referred to as the +5·8-kb site, had been identified in the first intron of the human ABO blood group gene. Subsequent studies revealed that either a 5·8-kb deletion including the +5·8-kb site or disruption of a GATA factor binding motif at the site was present in all Bm and ABm individuals examined. We investigated the molecular mechanism of the Am phenotype, which is analogous to the Bm phenotype.

MATERIALS AND METHODS

Genomic DNAs were prepared from peripheral blood of two Am individuals, and the nucleotide sequences were investigated using PCR and direct sequencing. Electrophoretic mobility shift assay (EMSA) and promoter assay with K562 cells were carried out.

RESULTS

A novel 23-bp nucleotide deletion was found at the +5·8-kb site in both individuals. EMSAs demonstrated binding of the transcription factor RUNX1 to the nucleotides within the deletion. Promoter assays showed that the deletion reduced the transcriptional activity of the +5·8-kb site.

CONCLUSION

Deletion of the 23-bp nucleotides including the RUNX1 binding site decreases transcription of the A allele, resulting in the reduction in A antigen expression in the Am phenotype.

Brownian motion and nonequilibrium statistical mechanics

This article is a personal reflection of the branch of nonequilibrium statistical mechanics called the linear response theory that has as its heart the fluctuation-dissipation thereom, which states that irreversible processes ip nonequilibrium are necessarily related to thermal fluctuations in equilibrium. Its origi lies in the Einstein relation for the diffusion constant and the mobility of a Brownian particle. The short history of the fluctuation-dissipation theorem is described. Then the linear response theory is brifly summarized and the meaning of stochastization is considered. The Langevin equation approach and its extensions are reviewed.

Evaluation of a novel kit for the rapid detection of extended-spectrum beta-lactamases

Since a method of rapidly detecting extended-spectrum beta-lactamase (ESBL) production in gram-negative isolates from patients with severe infection is urgently required, the present study of a novel commercial kit was conducted. The Cica-Beta Test I (Kanto Chemical, Tokyo, Japan) is designed for the rapid detection of ESBL in gram-negative bacteria directly from isolated colonies in a 15-min protocol. In this study, a total of 304 strains of Klebsiella spp., Escherichia coli and Proteus mirabilis were tested using the novel kit and the phenotypic confirmatory disk test using cefotaxime and ceftazidime with and without clavulanate. The kit showed 95.5 and 98.1% sensitivity and specificity, respectively, as compared to the disk test, and thus proved to be an appropriate tool for the rapid detection of ESBL.

Effects of consonantal context on perceptual assimilation of American English vowels by Japanese listeners

This study investigated the extent to which adult Japanese listeners' perceived phonetic similarity of American English (AE) and Japanese (J) vowels varied with consonantal context. Four AE speakers produced multiple instances of the 11 AE vowels in six syllabic contexts /b-b, b-p, d-d, d-t, g-g, g-k/ embedded in a short carrier sentence. Twenty-four native speakers of Japanese were asked to categorize each vowel utterance as most similar to one of 18 Japanese categories [five one-mora vowels, five two-mora vowels, plus/ei, ou/ and one-mora and two-mora vowels in palatalized consonant CV syllables, C(j)a(a), C(j)u(u), C(j)o(o)]. They then rated the "category goodness" of the AE vowel to the selected Japanese category on a seven-point scale. None of the 11 AE vowels was assimilated unanimously to a single J response category in all context/speaker conditions; consistency in selecting a single response category ranged from 77% for /eI/ to only 32% for /ae/. Median ratings of category goodness for modal response categories were somewhat restricted overall, ranging from 5 to 3. Results indicated that temporal assimilation patterns (judged similarity to one-mora versus two-mora Japanese categories) differed as a function of the voicing of the final consonant, especially for the AE vowels, /see text/. Patterns of spectral assimilation (judged similarity to the five J vowel qualities) of /see text/ also varied systematically with consonantal context and speakers. On the basis of these results, it was predicted that relative difficulty in the identification and discrimination of AE vowels by Japanese speakers would vary significantly as a function of the contexts in which they were produced and presented.

Metabolism of 2-nitrofluorene, 2-aminofluorene and 2-acylaminofluorenes in rat and dog and the role of intestinal bacteria

1. The in vivo metabolism of 2-nitrofluorene (NF), an environmental pollutant, and 2-aminofluorene (AF) and its acylated derivatives, 2-formylaminofluorene (FAF) and 2-acetylaminofluorene (AAF), was examined in rat and dog. 2. 7-Hydroxy-2-nitrofluorene, 5-hydroxy-2-nitrofluorene, AF, AAF, FAF, 7-hydroxy-2-aminofluorene, 5-hydroxy-2-aminofluorene, 7-hydroxy-2-acetylaminofluorene, 5-hydroxy-2-acetylaminofluorene, 7-hydroxy-2-formylaminofluorene and 5-hydroxy-2-formylaminofluorene were identified as urinary and faecal metabolites of NF in rat and dog. 3. AAF and its hydroxylated derivatives were detected as major metabolites of NF in rat, but FAF and its hydroxylated metabolites were mainly excreted in dog. 4. AF, AAF, FAF and their hydroxylated metabolites were also identified as urinary and faecal metabolites of AF, AAF or FAF in rat, suggesting that AAF and FAF are interconverted via AF. 5. Treatment of rat and dog with antibiotics significantly decreased the urinary and faecal excretion of AF and its derivatives after oral administration of NF, and partly decreased the excretion of acylated metabolites after an oral dose of AF. 6. The caecal contents of untreated rats and some species of intestinal bacteria exhibited nitro-reductase activity toward NF, and acylating activity toward AF, affording AAF and FAF.

The masking effect in foreign speech sounds perception revealed by neuromagnetic responses

The backward masking effect on non-native consonants by a following vowel was examined using neuromagnetic responses to synthesized speech sounds. Native speakers of Japanese were presented with sequences of frequent (85%) and infrequent (15%) speech sounds (/ra/ and /la/ respectively, no /l/ /r/ contrast in Japanese language). The duration of the stimuli was 110 ms in a short session and 150 ms in a long session. In the short session, the stimuli were terminated in the course of the transition from the consonant to the vowel to diminish the masking effect from the vowel part. A distinct magnetic counterpart of mismatch negativity (MMNm) was observed for the short session, whereas a smaller MMNm was observed for the long session.

Horizontal inclination of the longitudinal axis of the colonic J-pouch: defining causes of evacuation difficulty

PURPOSE

Functional outcome after low anterior resection for rectal cancer is improved by the construction of a colonic J-pouch. One disadvantage of this type of reconstruction is evacuation difficulty, which has been associated with large pouches. The purpose of this study was to elucidate the causes of evacuation difficulty in large pouches using pouchography.

METHODS

The angle between the longitudinal axis of the pouch and the horizontal line (pouch-horizontal angle) on lateral pouchography was determined in 26 patients with 10-cm J-pouch reconstructions (10-J group) and 27 patients with 5-cm J-pouch reconstructions (5-J group). Measurement were made at three months, one year, and two years after surgery. Clinical function was evaluated using a questionnaire one year postoperatively.

RESULTS

The pouch-horizontal angle in the 10-J group was significantly smaller than that in the 5-J group at all three time points. In both groups the pouch-horizontal angle at one year was significantly smaller than that at three months. There were no significant differences between the pouch-horizontal angles at one and two years. An evacuation difficulty was significantly more common in the 10-J group than the 5-J group.

CONCLUSIONS

The evacuation difficulty observed in patients with large colonic J-pouch reconstructions may be attributed to the development of a horizontal inclination within one year of surgery.

High ligation of the inferior mesenteric artery with hypogastric nerve preservation in rectal cancer surgery

We describe herein a technique of performing upward node dissection following high ligation of the inferior mesenteric artery for patients with T3 and T4 rectal carcinomas. The course of the hypogastric nerve is confirmed macroscopically during the procedure to ensure its preservation. This technique offers both increased radicality and the prevention of ejaculatory dysfunction.

Examination of nodal metastases by a clearing method supports pelvic plexus preservation in rectal cancer surgery

PURPOSE

In rectal cancer surgery preservation of urinary and sexual function is attempted by means of operations preserving the autonomic nerves of the pelvic plexus. Emergence of residual cancer because of a more shallow plane of dissection is a problem of concern with these methods, so we examined indications for pelvic plexus preservation.

METHODS

We studied 198 patients with rectal carcinoma who underwent abdominopelvic lymphadenectomy. Lymph nodes along the superior hemorrhoidal artery and middle hemorrhoidal artery medial to the pelvic plexus were defined as perirectal nodes, and nodes along the middle hemorrhoidal artery lateral to the pelvic plexus and along the internal iliac artery represented lateral intermediate nodes. Node metastases were examined by the clearing method.

RESULTS

Metastasis to perirectal nodes occurred in 12.5 percent in patients with pT1 tumors, 28.9 percent of those with pT2 tumors, and 50.0 percent of those with rectosigmoid junctional cancer. Metastasis to lateral intermediate nodes was absent in patients with pT1 or pT2 tumors and was as low as 2.5 percent in patients with rectosigmoid junctional cancer.

CONCLUSIONS

In patients with T1, T2, and rectosigmoid junctional cancer, perirectal node dissection is necessary, but chances of residual cancer should remain minimal when the pelvic plexus is preserved.

Coloanal anastomosis using a circular stapling device following perineal rectosigmoidectomy for rectal prolapse

Perineal rectosigmoidectomy with a hand-sewn anastomosis is thought to be the most appropriate procedure for elderly patients deemed unfit to tolerate a major abdominal operation. However, the use of a circular stapling device to perform the coloanal anastomosis following rectosigmoidectomy shortens the operative time and provides a more secure anastomosis than the traditional hand-sewn technique.

[Ocular blood flow defect in gaze-evoked amaurosis]

PURPOSE

To investigate the mechanism of gaze-evoked amaurosis.

CASE

A patient with an optic nerve tumor presented gaze-evoked amaurosis. A large central scotoma and constricted visual field were detected after shifting the gaze laterally. However, the patient did not notice this change until his fellow eye was occluded. Computed tomography/magnetic resonance imaging (CT/MRI) demonstrated a tubularly enlarged optic nerve extending for 1 cm from the eye ball, and the condition was judged to be optic nerve sheath meningioma. He underwent fluorescein fundus angiography twice, once during straight gaze and again during lateral gaze.

RESULTS

Manifestly decreased blood flow in the central retinal artery and filling defect in the optic nerve head were seen during lateral gaze.

CONCLUSION

Forced lateral gaze may have increased the intra-optic nerve pressure at the optic nerve head and decreased the blood flow of the central retinal artery and peripapillary choroidal flow irrigating the optic nerve head.

An evaluation of neural invasion in esophageal cancer

It is well known that the operative results for esophageal cancer, especially thoracic esophageal cancer, are not favorable. We analyzed the relationship between neural invasion (NI) and histopathologic factors and recurrence types in 104 patients who underwent resection of esophageal cancers with T2 or greater depth of invasion of the esophageal wall. The implications of NI as a prognostic indicator were also examined. Of the 104 patients, 48 (46.2%) were NI-positive (NI(+)) and 56 (53.8%) were NI-negative (NI(-)). The NI(+) patients had a higher ratio of type 3 cancer. Concerning the histopathologic factors, there was a significant relationship between NI and lymph node metastasis (N) and between NI and lymphatic vessel invasion (ly) (P < 0.05). Examining the types of recurrence, namely hematogenous, lymphogenous, and local/stump, as well as pleural or peritoneal dissemination, a relationship was observed between lymphogenous recurrence and N or ly, and between local/stump recurrence and NI. The prognosis of the NI(+) patients was significantly different from that of the NI(-) patients. According to a multivariate analysis, NI and N were significant prognostic factors. These findings demonstrate that NI is an important prognostic factor closely related to local recurrence in patients with esophageal cancer. Thus, when treating advanced esophageal cancer with T2 or greater depth of invasion, NI and lymph node excision should be considered.

Anterior resection following posterior transsacral stapling and transection of the anal canal for low-lying rectal cancer in males

In anterior resection with anastomosis using the double-staple technique for low-lying rectal cancer in male patients, the approach to the anal canal with a stapling instrument via the abdominal area is limited by the narrow pelvis. The stapling and transection of the anal canal via the posterior transsacral approach prior to performing an anterior resection thus enables the lower rectum and anal canal to be visualized, so that the anal canal can be accurately stapled and transected even in male patients with a narrow pelvis.

Indication for using high ligation of the inferior mesenteric artery in rectal cancer surgery. Examination of nodal metastases by the clearing method

PURPOSE

In surgery for rectal cancer, it is unclear whether the inferior mesenteric artery should be ligated at a high or low position. The study contained herein was undertaken to clarify the indications for high ligation of the inferior mesenteric artery.

METHODS

Subjects included 198 patients with rectal cancer who underwent resection with high ligation of the inferior mesenteric artery. Nodal metastases were examined by the clearing methods.

RESULTS

The incidence of metastases to the lymph nodes surrounding the origin of the inferior mesenteric artery (root nodes) was 8.6 percent. Inferior mesenteric artery root nodal metastases occurred more frequently with pT3 and pT4 cancer. The five-year survival rate in patients with inferior mesenteric artery root nodal metastases was 38.5 percent; this rate was significantly lower than in those without inferior mesenteric artery root nodal metastases (73.4 percent).

CONCLUSIONS

Although the five-year survival rate in patients with inferior mesenteric artery root nodal metastases was lower than in those without metastases, inferior mesenteric artery root nodal dissection should be performed after high ligation of the inferior mesenteric artery for patients with pT3 and pT4 cancers.

Indications for colonic J-pouch reconstruction after anterior resection for rectal cancer: determining the optimum level of anastomosis

PURPOSE

Functional outcome after anterior resection for rectal cancer is improved by colonic J-pouch reconstruction compared with straight anastomosis. The indications for colonic J-pouch reconstruction have yet to be determined. Therefore, we attempted to determine the level at which J-pouch reconstruction provides an advantage over straight anastomosis.

METHODS

A total of 48 patients who underwent 5-cm colonic J-pouch reconstruction (J-pouch group) and 80 patients who underwent straight anastomosis (straight group) underwent functional assessment one year postoperatively.

RESULTS

The functional outcome in the J-pouch group was significantly better than that in the straight group when the distance of the anastomosis from the anal verge was less than 8 cm. The difference was particularly obvious when the level of the anastomosis was below 4 cm. However, functional outcome in the straight group when the anastomosis was between 9 and 12 cm from the anal verge was also satisfactory and did not differ from that in the J-pouch group when the anastomosis was between 5 and 8 cm from the anal verge.

CONCLUSIONS

Colonic J-pouch reconstruction is indicated when the distance of anastomosis from the anal verge is less than 8 cm, and it is essential when the distance is less than 4 cm.

Phenotypic features of selective T cell deficiency characterized by absence of CD8+ T lymphocytes and undetectable mRNA for ZAP-70 kinase

Selective T cell deficiency is a rare immune deficiency characterized by the absence of CD8+ T lymphocytes and depressed/absent T cell function. This syndrome has been associated with mutations in the gene for ZAP-70, a tyrosine kinase that has profound effects on signaling via the T cell receptor. In this paper we describe a patient with selective T cell deficiency and certain phenotypic features that are unique among the small number of patients described. The patient had virtually absent T cell function, hypogammaglobulinemia, and no response to vaccination. The T lymphocytes failed to respond to mitogenic stimuli, even in the presence of exogenous interleukin 2. Similar to other patients with this disorder, the T cells were capable of proliferating when stimulated by pharmacologic agents such as phorbol ester and ionomycin. While peripheral blood T cells had limited capability to increase cytosolic Ca2+ levels in response to mitogenic stimulation, thymocytes responded to a large panel of antibodies and mitogens. This report broadens the spectrum of clinical presentations associated with selective T cell deficiency and, for the first time, compares the responses of both peripheral T cells and thymocytes. The data support the concept that the defect in signal transduction resulting from the absence of ZAP-70 is primarily manifested following export of T lymphocytes from the thymus and that selection of CDS-positive T cells is dependent on the presence of ZAP-70.

Comparison between the Japanese general rules and the TNM system in the regional lymph node classification of carcinoma of the colon

BACKGROUND

Metastasis to regional lymph nodes from carcinoma of the colon is an important prognostic factor. In the tumor, node, metastasis classification, node metastases are classified into four grades based on the number and distribution of metastatic nodes. In the Japanese General Rules for Clinical and Pathological Studies on Cancers of the Colon, Rectum and Anus, node metastases are classified into four grades based solely on the distribution of metastatic nodes.

STUDY DESIGN

Based on the findings of node metastases in 152 patients with carcinoma of the colon obtained by the clearing method, the node classifications by the Japanese General Rules and tumor, node, metastasis classifications were compared.

RESULTS

The case distribution by the Japanese General Rules grading was 38.2 percent in n(-), 30.3 percent in n1(+), 19.7 percent in n2(+), and 11.8 percent in n3(+) disease. In the tumor, node, metastasis classification, the distribution was 22.4 percent in pN1 and pN3 and 17.1 percent in pN2 disease. The five-year survival rate by the Japanese General Rules was 97.9 percent in n(-), 72.6 percent in n1(+), 51.2 percent in n2(+), and 30.0 percent in n3(+) disease, whereas in tumor, node, metastasis classification, this rate was 79.4 percent in pN1, 45.2 percent in pN2, and 44.8 percent in pN3 disease.

CONCLUSIONS

In the classification of regional node metastases from carcinoma of the colon, the Japanese General Rules showed a wider range in distribution and 5-year survival rate compared with the tumor, node, metastasis system.

Analysis of regional lymph node metastases from rectal carcinoma by the clearing method. Justification of the use of sigmoid in J-pouch construction after low anterior resection

PURPOSE

It has been reported that functional outcome following low anterior resection of resection of rectal cancer is improved by construction of a colonic J-pouch compared with straight anastomosis. Hence, we tried to justify use of the sigmoid colon in the construction of a J-pouch by the analysis of regional lymph node metastases.

METHODS

A total of 182 patients underwent resection for rectal cancer. Node metastases were examined by the clearing method. According to Japanese General Rules for Clinical and Pathological Studies on Cancer of the Colon, Rectum and Anus (JGR), nodes were classified into the perirectal nodes (PR-N), pericolic nodes (PC-N), central intermediate nodes (C-IM-N), central main nodes (C-M-N), lateral intermediate nodes (L-IM-N), and lateral main nodes (L-M-N).

RESULTS

Metastatic rate (number of patients with node metastases/total number of patients) of PR-N was 57.1 percent. Metastatic rate of C-IM-N was 18.7 percent and that of C-M-N was 7.1 percent. Metastatic rates of L-IM-N and L-M-N were 8.8 and 3.3 percent, respectively, and both were highest in the case of lower rectal cancer. Metastatic rate of PC-N was only 1.1 percent. The number of cases without node metastases (n(-) cases) was 78, that with only PR-N metastases (PR-N cases) was 63, that with intermediate but not main node metastases (IM-N cases) was 29, and that with main node metastases (M-N cases) was 12. Five-year survival rate after curative resection was 88.5 percent for n(-) cases, 70.9 percent for PR-N cases, 65.9 percent for IM-N cases, and 41.7 percent for M-N cases.

CONCLUSIONS

In low anterior resection, high ligation of the inferior mesenteric artery and dissection of C-M-N, C-IM-N and PR-N are necessary, with the addition of the L-IM-N and L-M-N in the case of lower rectal cancer. Resection of sigmoid colon is not required, and therefore, a J-pouch can be constructed using the sigmoid colon. Nodal classification according to the JGR was predictive of case distribution and five-year survival rate.

Functional outcome after low anterior resection with low anastomosis for rectal cancer using the colonic J-pouch. Prospective randomized study for determination of optimum pouch size

PURPOSE

Functional outcome after low anterior resection with ultralow coloanal anastomosis for rectal cancer is improved by construction of a colonic J-pouch vs. straight anastomosis. Optimum size of this pouch has yet to be determined. Therefore, we initiated a prospective, randomized trial using 5-cm and 10-cm pouches to determine this size.

METHODS

Patients with tumors 5 to 10 cm from the anal verge were included in the study. Before a low anterior resection anastomosis was performed, patients were randomized to either a 5-cm J-pouch group (5-J group) or a 10-cm J-pouch group (10-J group). Functional assessments were performed one year postoperatively. Clinical functions were evaluated using a functional scoring system. Physiologic functions, such as sphincter and reservoir function, were evaluated by anorectal manometry and evacuation function by the balloon expulsion and saline evacuation tests.

RESULTS

Forty patients among 43 randomized patients were assessed for functional outcome one year postoperatively (5-J group, n = 20; 10-J group, n = 20). The functional score was similar for the two groups, although reservoir function in the 5-J group was significantly less than in the 10-J group. Sphincter function was similar between the two groups. Evacuation function in the 5-J group was significantly superior to that in the 10-J group.

CONCLUSIONS

The 5-cm J-pouch conferred adequate reservoir function without compromising evacuation.

[Diagnosis and therapy for metastatic liver cancer]

Hepatic metastases occur frequently in patients with colorectal cancer. Patients with advanced cancer should be followed carefully after curative resection of the primary lesions for the early detection of the recurrence. If hepatic metastasis is suspected on the basis of rising CEA levels, more sophisticated imaging techniques, such as ultrasound, computed tomography, magnetic resonance imaging and hepatic angiography should be employed for the diagnosis. However, these tests are not cost-effective and not warranted on a routine follow-up basis. To be more cost-effective, a relatively simple and sensitive test or group of tests should be used. The authors have proposed that the basement membrane producibility of the primary lesion yields the most important information predicting a liver metastasis; the basement membrane producing cancer highly metastasizes to the liver. In contrast, more than 90% of non-producing cancer does not metastasize to the liver. The basement membrane producibility is easily examined by laminin staining. In the treatment of hepatic metastases, hepatic resection is the preferred approach when the metastases are located in a resectable segment or can be encompassed by as many as five wedge resections, but these scenarios are relatively uncommon. For unresectable disease, chemotherapy and intravenous and/or intra-arterial embolization are viable alternatives. Loco-regional treatment may offer a pharmacological advantage since a liver metastasis is almost exclusively fed by the hepatic artery. A pilot study we conducted on hepatic infusion chemotherapy combined with interleukin-2 (IL-2.MF) revealed very encouraging results (response rate: 76%), and further study in a prospective randomized trial confirmed this high response rate. Adjuvant IL-2.MF infusion therapy after curative resection of liver metastases is also effective for the prevention of recurrence in the residual liver. Based on the data, we conclude that multimodal treatments of hepatic resection and loco-regional infusion of immuno-chemotherapy (IL-2.MF) make it possible to control both resectable and unresectable liver metastases.

Second-look operation for recurrent colorectal cancer based on carcinoembryonic antigen and imaging techniques

PURPOSE

The usefulness of postoperative carcinoembryonic antigen (CEA) monitoring and improvements in imaging techniques have renewed enthusiasm for second-look operations (SLO) as the most effective treatment for recurrent colorectal cancer by reresection following early detection. The aim of our study is to evaluate the role of CEA and imaging techniques-directed SLO.

METHODS

Seven hundred fifty-six patients with Dukes Stages B and C, who had undergone curative resection, were monitored postoperatively using CEA and imaging techniques. An SLO was performed on any potentially resectable recurrence, and in addition, an SLO was done when a persistently rising CEA value was detected.

RESULTS

Recurrence developed in 18.8 percent (142/756) of patients, and 90.8 percent (129/142) of the recurrences were detected within the first three years following curative resection. When comparing carcinomas of the colon with that of the rectum, the former were associated with significantly more hepatic and intraabdominal recurrences, whereas the latter had significantly more locoregional and pulmonary recurrences. Seventy-two patients underwent SLO. Of these patients, 54.2 percent (39/72) had all of their disease resected, and 1.4 percent (1/72) had no detectable disease at the SLO. Among the 142 patients with recurrence, 71 (50 percent) patients underwent SLO. The resectable group at SLO carried a significantly better survival than the unresectable recurrence group (41.3 vs. 5.2 percent; P<0.01).

CONCLUSIONS

Complete removal of colorectal cancer recurrences by SLO, on the basis of postoperative, follow-up CEA and imaging technique findings, results in improved survival.

[Prognostic predictors in colorectal cancer]

The prognostic significance of clinicopathologic factors in colorectal cancer was evaluated in a multivariate analysis. The most important independent factor affecting survival was stage (depth of penetration through the bowel wall and the presence of positive lymph nodes). All other clinicopathologic factors were of less importance than stage in determining prognosis. Although the prognostic relevance of biologic and molecular variables has been investigated extensively, the importance of these factors as prognostic predictors remains uncertain and further studies are needed.

Immunohistochemical studies of basement-membrane in colorectal-cancer and primary cultured-cells

The basement membrane (BM), a structure of crucial importance in the invasion and metastasis of cancers, was studied immunohistochemically using colorectal cancer tissues. In addition, BM-like structures formed in the primary culture of cancer cells were compared to the BM of primary cancers. BM was stained with antibodies specific for laminin, type IV collagen, fibronectin, and heparan sulfate proteoglycan. In the normal colon these compounds were detected in the glandular BM, vascular BM and perinervium by immunostaining. Components of the BM were not stained in some cancer tissues, and BM staining essentially disappeared in the invasive front of cancer in several cases. Of whole cancer tissues, 10 of 23 cases (43.5%) were BM positive and the remaining 13 cases (56.5%) were negative. A three dimensional primary culture of colorectal cancer cells was performed in collagen gel. The cancer cells obtained from primary cancers which had densely stained for BM formed a BM-like structure in primary culture, but those from negatively stained cancer tissues showed no BM-like structures. The BM-like structure in the primary culture was shown to have the same components as the true BM by immunohistochemistry, and this membranous structure was shown to have originated in the cancer cells. In the primary culture without any BM-like structures, granules containing BM components were observed around tumor cell clusters. The primary culture of tumor cells in collagen gel is closely related to the original tumor tissues and therefore may provide a good model system for the investigation of BM in cancer.

The role of basement membrane in colorectal cancer invasion and liver metastasis

BACKGROUND

Basement membrane (BM) is a specialized extracellular matrix component that plays a key role in tumor invasion and metastasis.

METHODS

Immunohistochemical staining for two major components of BM, type IV collagen (C IV), and laminin (LN), utilizing avidin-biotin-peroxidase complex detection to examine 182 primary colorectal cancers (pT2 or greater) and 20 liver metastases.

RESULTS

The distribution of C IV was the same as of LN in colorectal cancer tissue, and in normal tissue. Both C IV and LN staining were more frequently positive in the superficial zone but infrequently in the deep zone of the primary tumor. BM preservation, C IV and LN staining in both the superficial and deep zones, was seen in 18.7% of the subjects. The rate of BM preservation significantly decreased with increasing histologic grade (P < 0.01). No correlation was observed between pT number and BM preservation. The rate of BM preservation in cases of liver metastasis was 84.4%, significantly higher than the rate in cases without liver metastasis (P < 0.001). BM was observed even at the advancing front of tumor invasion and was preserved in 95.0% of the liver metastases.

CONCLUSIONS

BM is a functional substance that appears to accompany cancer rather than function as a structural barrier against cancer invasion and liver metastasis.

Metastases from carcinoma of the colon and rectum detected in small lymph nodes by the clearing method

A study of regional lymph node metastases was performed using the clearing method in 322 patients with carcinoma of the colon and rectum (140 with carcinoma of the colon and 182 with carcinoma of the rectum) who had undergone surgical resection. The mean number of nodes examined per patient was 76.4 and the metastatic rate (patients with metastases divided by the total of patients) was 61.4 percent, with a metastatic incidence (nodes with metastases divided by the total of examined nodes) of 6.4 percent for carcinoma of the colon using the clearing method. For carcinoma of the rectum, the mean number of nodes examined was 73.7 with a metastatic rate of 57.1 percent and a metastatic incidence of 7.1 percent. In contrast, node analysis by the conventional manual method resulted in a mean of 18.1 nodes being examined, with a metastatic rate and incidence of 42.1 and 12.8 percent, respectively, for carcinoma of the colon. Manual examination of lymph nodes in carcinoma of the rectum resulted in a mean of 21.2 nodes being examined, with a metastatic rate and incidence of 50.0 and 16.8 percent, respectively. Compared with the manual method, the clearing method provided a greater number of nodes, a higher metastatic rate and a lower metastatic incidence. These differences may be explained by the detection of metastatic regional nodes smaller than 4 millimeters in maximum diameter by the clearing method. By TNM classification there were more pN3 than pN2 lesions. The five year survival rate after curative resection was 78.5 percent for pN1 lesions, 45.7 percent for pN2 lesions and 45.4 percent for pN3 lesions for carcinoma of the colon and 72.7 percent for pN1 lesions, 75.0 percent for pN2 and 53.9 percent for pN3 lesions for carcinoma of the rectum. There was no significant survival difference between the patients with pN1, pN2 and pN3 carcinomas. The presence of regional nodes metastases should be examined in detail. Therapies and prognosis of carcinoma of the colon and rectum should be discussed based on accurate staging.

Distribution of metastatic lymph nodes in colorectal cancer by the modified clearing method

PURPOSE

The aim of this study was to clarify the distribution of lymph node metastasis in colorectal cancer. We also examined the relationship between the primary tumor (T) and the regional node (N) categories of the TNM (primary tumor, regional nodes, metastasis) classification.

METHOD

Lymph nodes of surgical specimens in 311 consecutive patients with colorectal cancer were studied using the modified clearing method.

RESULTS

Lymph node metastasis was seen in 59.2 percent of the total cases. The upward metastasis rate was 30.7 percent. In the longitudinal spread, most of the lymph node metastasis was seen within 10 cm. On the oral side in rectal cancer, there was no metastasis beyond 4 cm. The lateral metastasis rate in rectal cancer was 8.8 percent and in the lower rectum, the rate of cancer within 6 cm from the anal verge or beyond pT3 was much higher.

CONCLUSION

In the TNM classification, there was no significant difference between colon and rectal cancer except pT1 with rectal cancer. In the lower rectal cancer within 6 cm from the anal verge or beyond pT3, there is a high risk of lateral metastasis, and lateral lymph node dissection or radiation therapy should be performed.

A combined chemo-endocrine treatment with tegafur, adriamycin, methotrexate and tamoxifen for advanced renal cell carcinoma

Eight patients with advanced renal cell carcinoma were given a new chemo-endocrine treatment with tegafur, adriamycin, methotrexate and tamoxifen. Estrogen receptor was detected in five cases from renal or metastatic tumors. The patients were medicated with 800-1, 200mg of tegafur and 20 mg of tamoxifen daily po and 20mg of adriamycin and 10 mg of methotrexate iv intermittently at two week intervals. Two patients were regarded as CR, two as PR, one as NC and three as PD. Two out of three with estrogen receptor and one out of two without estrogen receptor responded favorably to this treatment. Side effects observed during the treatment were Grade II nausea/vomiting in six, Grade II leukopenia in three, Grade I thrombocytopenia in two, and Grade I hepatoxicity in three patients. The patients were found to be enjoying a good quality of life during the treatment because of lowered toxicity. This treatment can be regarded as a good treatment modality for advanced renal cell carcinoma.

Immunomodulatory effects of ursodeoxycholic acid on immune responses

Ursodeoxycholic acid was recently recognized as an effective agent in the treatment of primary biliary cirrhosis. Experimental evidence supporting the usefulness of ursodeoxycholic acid as a potentially beneficial therapeutic agent for primary biliary cirrhosis has been reported from the biochemical and physiological aspects. In this study, we investigated the direct effects of ursodeoxycholic acid on immunoglobulin and cytokine production in vitro using plaque-forming cell assay and enzyme-linked immunosorbent assay. It was demonstrated that ursodeoxycholic acid suppressed the production of IgM, IgG and IgA induced by Staphylococcus aureus Cowan I in peripheral blood mononuclear cells derived from healthy subjects and patients with primary biliary cirrhosis and also in human B lymphoma cell lines. Furthermore, ursodeoxycholic acid suppressed interleukin-2 and interleukin-4 production induced by concanavalin A and interferon-gamma production induced by polyinosinic-polycytidylic acid, but it did not affect interleukin-1 and interleukin-6 production induced by lipopolysaccharide in peripheral blood mononuclear cells. In addition, ursodeoxycholic acid suppressed the concanavalin A-induced thymocyte proliferation mediated by interleukin-1. Cytotoxicity against lymphocytes was not observed at the concentrations of ursodeoxycholic acid used. These results suggest that the beneficial effect of ursodeoxycholic acid in primary biliary cirrhosis is mediated in part by immunosuppression.

Heat shock protein Hsp60-reactive gamma delta cells: a large, diversified T-lymphocyte subset with highly focused specificity

Previously, we detected a subset of gamma delta T cells in the newborn mouse thymus that responded to the mycobacterial heat shock protein Hsp60, as well as with what seemed to be a self-antigen. All of these cells expressed V gamma 1, most often in association with V delta 6+. It was not clear, however, whether similar, mature gamma delta cells with Hsp60 reactivity are common outside of the thymus, or rather, whether they are largely eliminated during development. From the data presented here, we estimate that gamma delta cells responding to Hsp60 comprise 10-20% of normal splenic and lymph node gamma delta T cells. Such cells, derived from adult spleen, always express a V gamma 1-J gamma 4-C gamma 4 gamma chain, although not all cells with this gamma chain show Hsp60 reactivity. Many of these V gamma 1+ cells also express V delta 6-J delta 1-C delta, though fewer than in V gamma 1+ cells from the newborn thymus. Extensive diversity is evident in both the gamma and delta chain junctional amino acids of the receptors of these cells, indicating that they may largely develop in the thymus of older animals or undergo peripheral expansion. Finally, we found that all such cells responding to both a putative self-antigen and to mycobacterial Hsp60 respond to a 17-amino acid synthetic peptide representing amino acids 180-196 of the Mycobacterium leprae Hsp60 sequence. This report demonstrates that a large subset of Hsp60-reactive peripheral lymphoid gamma delta T cells preexists in normal adult mice, all members of which respond to a single segment of this common heat shock protein.

T-cell repopulation following neonatal injection of non-obese diabetic (NOD) mice with anti-T-cell antibodies

Non-obese diabetic (NOD) mice injected with CD3 antibody as newborns have a reduced incidence of diabetes, raising the possibility that the neonatal injection caused a long-lasting change in circulating T cells. The present study shows that NOD and BALB/c mice injected with soluble CD3 antibody in the first 2 days of life sustained an 80-95% reduction in the number of circulating T cells lasting for 2-3 weeks, with T cells returning after 4 weeks, and reaching control values after 6 weeks. The T cells which appeared in intact mice 4-6 weeks after injection showed no excess of T-cell receptor (TcR) delta expressing cells. They had a similar distribution into CD4 and CD8 subsets as uninjected controls, and a similar usage and cell surface expression of four T-cell receptor V beta families. Labelled CD3 antibody was detected in the serum for up to 2 weeks after injection into neonates and was enriched in the thymus. Adoptively transferred T cells continued to be cleared from the circulation for 4 weeks following antibody injection. The properties of T cells which had been exposed to CD3 neonatally were investigated in animals who were first injected with CD3 antibody and then thymectomized. These animals had reduced numbers of T cells at 12 weeks of age. The surviving T cells showed a Ca2+ flux when stimulated but their proliferation in response to concanavalin A (Con A) was reduced, even in the presence of irradiated accessory cells or T-cell supernatant co-stimulator factors. Although the representation of four different V beta families was the same as in the uninjected controls, the density of expression of the T-cell receptor was reduced. The data indicate that the limited number of T cells which survive the injection are functionally deficient and that an intact thymus is required for full T-cell repopulation following neonatal CD3 injection into NOD mice.

Prevention of collagen induced arthritis in mice by treatment with an antibody directed against the T cell receptor alpha beta framework

Collagen induced arthritis (CIA) is an animal model of inflammatory polyarthritis. Type II collagen is the major matrix protein of hyaline cartilage. Susceptibility to CIA is linked to the Major Histocompatibility Complex Class II genes but the presence of T cells expressing specific variable beta (V beta) chain of their T cell receptor (TCR) is also required. Pretreatment with the monoclonal antibody H57-597 directed against the TCR alpha beta framework prevented the onset of arthritis in the majority of animals. The depletion of the T cell population did not lead to any apparent health problems. These experiments demonstrate the important role of the alpha/beta T cell and its receptors in the CIA model. Further, anti-TCR alpha beta antibodies may be of value in the therapy of autoreactive disorders.

A method for production of antibodies to human T-cell receptor beta-chain variable regions

Mouse T-cell hybridomas bearing human V beta elements were produced by transfection of human/mouse hybrid T-cell receptor beta-chain genes into a mouse T-cell hybridoma lacking an endogenous beta-chain gene. These hybridomas were entirely mouse in origin except for the human V beta region. These cells were used to immunize mice against human V beta elements. Mouse monoclonal antibodies have thus been generated against human V beta 13.1 and -13.2. We expect that the method outlined in this paper will be useful in the production of monoclonal antibodies specific for other human V beta or V alpha elements.

Recognition of a single hsp-60 epitope by an entire subset of gamma delta T lymphocytes

We can conclude that a large subset of gamma delta cells, present in both murine newborn thymus and in adult spleen, respond to the stress protein, hsp60. hsp60 seems to be stimulatory whether it is derived from a foreign pathogen such as mycobacteria, or whether it originates from the mouse's own cells. The gamma delta cells that respond to this antigen bear very similar receptors, all expressing V gamma 1 and most expressing V delta 6, although their junctional variations indicate that not all members of the subset stem from clonal expansion of only one or a few cells. The hsp60-reactive subset has not at this time been shown to "home" to an epithelial location, in contrast to other known gamma delta cell subsets, and may rather carry out its functions while in circulation. Whether the hsp60 antigen requires a "presenting" molecule remains at this point unclear, but because the gamma delta cells all respond to a synthetic peptide representing an epitope of hsp60, presentation is implied. Human gamma delta cells that respond to PPD from mycobacteria, as do the mouse hsp60-reactive gamma delta cells, have also been described, many as members of a major subset in peripheral blood, although only rarely have these been reported to respond to mycobacterial hsp60. The antigenic source in PPD for these cells has not yet been determined, but as for the mouse, a low molecular weight peptide appears to be sufficient for stimulation (P. Brennan and R. Modlin, personal communication). The PPD-reactive gamma delta cells, when their receptors have been characterized, have been found to express a V gamma 9+ chain. Some evidence indicates that these cells can also recognize self hsp60; hence, in several ways, this human subset has characteristics similar to the mouse hsp60-reactive subset. Perhaps gamma delta cells that respond to hsp60 play an important role, in both mice and humans, in the detection of transformed self cells or cells containing intracellular pathogens, that escape detection by alpha beta T cells.

Glucagon-induced alteration of serum bile acid level in patients with liver cirrhosis

Percent changes in serum total bile acid level after IV administration of 1 mg glucagon were measured in 61 cirrhotics. Thirty-three of 38 cases with Child's grade A disease showed a reduction of total bile acid level at 15 minutes; this level was maintained in the majority of them until 120 minutes. A similar mode of serial changes in total bile acid level was also shown in the cases with Child's grade B disease. On the other hand, only 2 of 10 cases with Child's grade C showed a reduction of total bile acid level at 15 minutes. Reduction of total bile acid level at 15 minutes after glucagon administration was mimicked by infusion of dibutyryl cyclic adenosine monophosphate. However, in 3 of 6 cases with elevated total bile acid level at 15 minutes after glucagon administration, dibutyryl cyclic adenosine monophosphate induced a reduction of total bile acid level. Also, it was confirmed that glucagon enhances the uptake of taurocholate into freshly isolated rat hepatocytes by activating Na(+)-dependent, carrier-mediated membrane transport system and observed that its effect is associated with elevation of Vmax (0.6114 nmol.min-1 x 10(6) cells-1 without glucagon; 0.975 nmol.min-1 x 10(6) cells-1 in glucagon added) but not with affecting Km (13.58 mumol/L without glucagon; 13.71 mumol/L with glucagon) or protein synthesis which is inhibited by cycloheximide. These observations suggest that glucagon enhances Na(+)-coupled membrane transport of bile acids in the liver and causes the reduction of serum total bile acid level and that a lack of this response may be indicative of membrane dysfunction in the liver.

Alpha beta T-lymphocyte depleted mice, a model for gamma delta T-lymphocyte functional studies

Adult mice can be depleted of essentially all mature alpha beta T lymphocytes by chronic treatment with the framework-recognizing, pan-specific anti-TCR alpha beta mAb, H57-597. Similar findings have been reported in rats, gamma delta cell populations remain essentially unaltered in size and reactivity. Suppression of alpha beta T-cell development results in the loss of alloantigen reactivity and of B-cell help, suggesting that gamma delta and alpha beta populations differ in their functional capabilities. Indirect effects of the antibody treatment include quantitative changes in splenic B cells, as well as reduced sizes and weights of experimental animals. alpha beta-suppressed mice and rats may provide model systems for studies on gamma delta cell function in vivo.