Nucleic acid-triggered tumoral immunity propagates pH-selective therapeutic antibodies through tumor-driven epitope spreading

Important roles of humoral tumor immunity are often pointed out; however, precise profiles of dominant antigens and developmental mechanisms remain elusive. We systematically investigated the humoral antigens of dominant intratumor immunoglobulin clones found in human cancers. We found that approximately half of the corresponding antigens were restricted to strongly and densely negatively charged polymers, resulting in simultaneous reactivities of the antibodies to both densely sulfated glycosaminoglycans (dsGAGs) and nucleic acids (NAs). These anti-dsGAG/NA antibodies matured and expanded via intratumoral immunological driving force of innate immunity via NAs. These human cancer-derived antibodies exhibited acidic pH-selective affinity across both antigens and showed specific reactivity to diverse spectrums of human tumor cells. The antibody-drug conjugate exerted therapeutic effects against multiple cancers in vivo by targeting cell surface dsGAG antigens. This study reveals that intratumoral immunological reactions propagate tumor-oriented immunoglobulin clones and demonstrates a new therapeutic modality for the universal treatment of human malignancies.

Frontotemporal dermoid cyst with incomplete dermal sinus tract in an adult: A case report

Background

Non-midline supratentorial dermoid cyst with dermal sinus tract has been rarely reported especially in adults. We recently experienced a noteworthy patient with frontotemporal dermoid cyst with incomplete dermal sinus tract.

Case Description

A 43-year-old female presented with recurrent subcutaneous mass in the left superolateral orbital region. She had a history of active bronchial asthma, which precluded her from contrast-enhanced imaging studies. Plain imaging studies showed a subcutaneous mass which was continuous with an intrasylvian fissure mass by a tract in the sphenoid ridge and the lesser wing of the sphenoid bone. Frontotemporal craniotomy was performed to reset the mass and the tract. Intraoperative finding showed no intradural tumor components. Extradural component was carefully removed focusing attention on the frontal branch of the facial nerve. The pathology was consistent with dermoid cyst and dermal sinus tract. Postoperatively, she had mild facial palsy of the corrugator supercilii (House and Brackmann Grade II). She was discharged home with modified Rankin scale 1.

Conclusion

Dermoid cyst needs to be included in the differential diagnosis of adult-onset subcutaneous mass in the frontotemporal regions. After thorough imaging studies for the presence and extent of the sinus tract, the symptomatic lesion should be excised completely once and for all.

Abstract A169: Combination of TPC-144, a reversible LSD1 inhibitor, and a hypomethylating agent resulted in synergistic antitumor efficacy in preclinical models of AML

Background: Lysine-specific demethylase 1A (LSD1/KDM1A) is a flavin adenine dinucleotide (FAD)-dependent histone demethylase that specifically modifies histone H3 lysine 4 and lysine 9. LSD1 activity is implicated in the pathogenesis of several human cancers, and recent studies indicated that the inhibition of LSD1 is a promising therapeutic strategy for acute myeloid leukemia (AML). Decitabine and azacitidine, FDA-approved agents for the treatment of AML and myelodysplastic syndrome, alter global DNA methylation by inhibiting DNA methyltransferases (DNMTs), resulting in apoptosis and differentiation. Since it is reported that LSD1 directly demethylates and stabilizes DNMT1 by protection from degradation, we hypothesized that an LSD1 inhibitor could augment anti-AML activity of DNMT inhibitors. Previously, we demonstrated that TPC-144, a novel reversible LSD1 inhibitor, was efficacious in preclinical models of AML. Here, we report the activity of TPC-144 in combination with decitabine in cell-based and in vivo studies. Material and Methods: In vitro studies on growth inhibition and apoptosis were conducted using AML cell lines by measuring cellular ATP content (Cell-Titer Glo, Promega) and sub-G1 population, respectively. For expression changes of surface markers, cells were stained with specific antibodies (BD Pharmingen) and analyzed by flow cytometry. mRNA levels of LSD1 target genes were quantitated by real-time PCR. LINE-1 methylation levels were evaluated in Global DNA Methylation-LINE-1 Kit (Active Motif). In vivo efficacy was evaluated in human AML xenograft models in SCID mice. TPC-144 and decitabine was administered orally or intraperitoneally, respectively. Results: The combination of TPC-144 and decitabine showed synergistic growth inhibition of human AML cells in vitro. TPC-144 enhanced apoptosis induction in combination with low-dose decitabine at the concentrations at which TPC-144 decreased DNMT1 protein levels and LINE-1 methylation levels. Combination treatment strongly increased expression of surface markers of differentiation such as CD86 and CD11b, compared with single-agent treatment. In AML xenograft models, the combination of TPC-144 and decitabine was tolerated without signs of hematopoietic toxicities, and demonstrated curative antitumor efficacy compared with each inhibitor alone in a decitabine-sensitive xenograft model. Importantly, the combination treatment of TPC-144 and decitabine exhibited strong antitumor efficacy even in a decitabine-insensitive AML model. Conclusions: TPC-144, a novel potent and selective reversible LSD1 inhibitor, demonstrated synergistic antitumor efficacy in combination with decitabine in human AML cell lines and xenograft models. This combination was well tolerated and showed strong efficacy not only in decitabine-sensitive but also in decitabine-insensitive AML models. Therefore, combination of TPC-144 and decitabine could enhance their therapeutic value for the treatment of AML patients.

Citation Format: Akiko Osada, Aki Kawagishi, Ryo Hatanaka, Takumitsu Machida, Kenjiro Ito, Satoshi Yamashita, Takahiro Ogawa, Tadashi Imaoka, Kenichi Matsuo, Teruhiro Utsugi, Yoshikazu Iwasawa. Combination of TPC-144, a reversible LSD1 inhibitor, and a hypomethylating agent resulted in synergistic antitumor efficacy in preclinical models of AML [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2017 Oct 26-30; Philadelphia, PA. Philadelphia (PA): AACR; Mol Cancer Ther 2018;17(1 Suppl):Abstract nr A169.

[Primary Lung Cancer Associated with Dilated Phase of Hypertrophic Cardiomyopathy;Report of a Case]

A 66-year-old man diagnosed as dilated phase of hypertrophic cardiomyopathy (D-HCM) was pointed out an abnormal shadow on routine chest radiography. The patient had past medical history of hypertension, congestive heart failure and chronic obstructive pulmonary disease. The computed tomography showed a 3.8 cm-sized tumor in the left lower lobe of the lung, and histopathological examination revealed squamous cell carcinoma (cT2aN0-1M0, cStage I B-II A). Cardiosonography showed diffuse hypokinesis from basal to mid area, and ejection fraction was 36.3%. Sporadic ventricular premature contraction was seen by the Holter electrocardiogram. The patient underwent left lower lobectomy with node lymph node dissection (ND1b). The circulatory condition of the patient was stable during surgery. After surgery, careful management of electrolytes and fluid infusion, and the regular medication was started again on the next day of surgery.

[Tension Pneumothorax Developing Hemothorax after Chest Tube Drainage]

A 61-year-old man visited a physician complaining of progressive chest pain and dyspnea. The chest radiography showed complete collapse of the right lung suggesting tension pneumothorax. The patient was transferred to our hospital. A small amount of the right pleural effusion was also seen in addition to pulmonary collapse on the chest radiography. Chest drainage was performed, and continuous air leakage was seen. At 2 hours later, air leakage was disappeared but the bloody effusion was noted. The chest radiography revealed massive effusion and the enhanced computed tomography showed active bleeding. The emergency surgery was conducted. The bleeding point was a ruptured vessel between the apical parietal pleura and the pulmonary bulla. Hemostasis and the resection of the bullae was performed. Careful observation after chest drainage is necessary to prepare unexpected hemothorax in case of tension pneumothorax with pleural effusion.

[Hemopneumothorax after thoracic sympathetic nerve block; report of a case]

A 72-year-old man, who had been treated pneumothorax 50 years ago, visited a physician complaining of dyspnea after thoracic sympathetic nerve block for postherpetic neuralgia. The patient was diagnosed as pneumothorax, and was consulted to our hospital. Clinical sign and the chest radiography suggested tension hemopneumothorax, and the chest drainage was immediately performed. Although bloody fluid of 1,100 ml was initially drained, no further increase was noted. The patient was discharged on the 21st hospital day.

[Results of non-rigid prosthetic reconstruction with expanded polytetrafluoro-ethylene( ePTFE) soft tissue patch following chest wall resection for malignant tumors]

Twenty patients underwent chest wall reconstruction using expanded polytetrafluoroethylene(ePTFE) soft tissue patch following resection between June 1996 and December 2012. The patients included 15 men and 5 women, aged 18 to 80 years. The indications for resection included 4 primary tumors, 8 metastatic tumors, and 8 infiltrating tumors. The lesions were located anteriorly in 10 patients, laterally in 5 patients and posteriorly in 5 patients. Skeletal resection involved an average of 2 ribs in 19 patients, and a partial sternectomy in 1 patient. The size of chest wall defects ranged from 20 to 210 cm2( mean, 69.8 cm2). Lung resection was performed in 7 patients included a wedge resection, 5 lobectomy, and a bilobectomy. Chest wall defects were closed primarily with ePTFE soft tissue patch. There were no critical complications or postoperative mortalities. The mean follow-up in all patients is 72.7 months. Recurrence of malignancy occurred in 10 patients included a local recurrence in 1 patient, and metastases in 9 patients. The overall postoperative 5-year survival rate is 61.0%. Non-rigid prosthetic reconstruction with ePTFE soft tissue patch provides satisfactory outcome. New prosthetic materials have to be examined whether they are superior to ePTFE soft tissue patch.

[Elderly Bochdalek hernia found out by intestinal obstruction]

A 78-year-old man, who had been pointed out elevation of the diaphragm by chest radiography, visited local physician complaining of abdominal pain and vomiting. He was referred to our hospital and was diagnosed as intestinal obstruction. The patient had neither respiratory symptoms nor findings of peritonitis. The radiography revealed intestinal gas with neveau formation in the left thorax. The computed tomography showed dilatation of the stomach and small intestine, and a diaphragmatic hernia was suspected. Although conservative treatment was started, radiographic and laboratory findings got worse on the 5th hospital day. The patient underwent surgery for a left diaphragmatic hernia with the intestinal obstruction. Diagnosis of Bochdalek hernia with hernia sac was established. The content of hernia was the perforated small intestine. Postoperative course was almost uneventful, and the patient was discharged on the 35th postoperative day without pyothorax. In treatment of adult Bochdalek hernia, early surgery is important because patients with incarceration or perforation often experience severe postoperative complication.

The Kelch repeat protein KLHDC10 regulates oxidative stress-induced ASK1 activation by suppressing PP5

Reactive oxygen species (ROS)-induced activation of Apoptosis signal-regulating kinase 1 (ASK1) plays crucial roles in oxidative stress-mediated cell death through the activation of the JNK and p38 MAPK pathways. However, the regulatory mechanism of ASK1 in the oxidative stress response remains to be elucidated. Here, we identified the kelch repeat protein, Slim, as an activator of ASK1 through a Drosophila misexpression screen. We also performed a proteomics screen and revealed that Kelch domain containing 10 (KLHDC10), a mammalian ortholog of Slim, interacted with Protein phosphatase 5 (PP5), which has been shown to inactivate ASK1 in response to ROS. KLHDC10 bound to the phosphatase domain of PP5 and suppressed its phosphatase activity. Moreover, KLHDC10 was required for H(2)O(2)-induced sustained activation of ASK1 and cell death in Neuro2A cells. These findings suggest that Slim/KLHDC10 is an activator of ASK1, contributing to oxidative stress-induced cell death through the suppression of PP5.

Modeling the spontaneous Ca2+ oscillations in astrocytes: Inconsistencies and usefulness

Spontaneous calcium (Ca2+) oscillations (SCOs) in astrocytes might be a crucial signaling for the multipurpose role of this type of cell in several brain functions. To interpret experimental data of astrocytic SCOs, which has been largely observed in the last decade, several groups have attempted to accommodate biophysical models that were developed in the past for Ca2+ signaling in other cell types. In most of the cases, only predictive strategies were used to estimate specific parameters of these modified models from actual experiments. In this study, we discuss the most remarkable models used to describe Ca2+ signaling in astrocytes. At the same time, we aim to revise the particulars of applying these models to interpret epifluorescent time series obtained from large regions of interest. Specially, we developed a detailed model for global Ca2+ signaling in the somata of astrocytes. In order to estimate some of the parameters in our model, we propose a deductive reasoning strategy, i.e., a statistical inference method that results from combining a filtering technique and a maximum likelihood principle. By means of computer simulations, we evaluate the accuracy of this estimation's strategy. Finally, we use the new model, in combination with a recent experimental findings by our group, to estimate the degree of cluster coupling inside the soma during the genesis of global Ca2+ events.

p38 MAPKs regulate the expression of genes in the dopamine synthesis pathway through phosphorylation of NR4A nuclear receptors

In Drosophila, the melanization reaction is an important defense mechanism against injury and invasion of microorganisms. Drosophila tyrosine hydroxylase (TH, also known as Pale) and dopa decarboxylase (Ddc), key enzymes in the dopamine synthesis pathway, underlie the melanin synthesis by providing the melanin precursors dopa and dopamine, respectively. It has been shown that expression of Drosophila TH and Ddc is induced in various physiological and pathological conditions, including bacterial challenge; however, the mechanism involved has not been fully elucidated. Here, we show that ectopic activation of p38 MAPK induces TH and Ddc expression, leading to upregulation of melanization in the Drosophila cuticle. This p38-dependent melanization was attenuated by knockdown of TH and Ddc, as well as by that of Drosophila HR38, a member of the NR4A family of nuclear receptors. In mammalian cells, p38 phosphorylated mammalian NR4As and Drosophila HR38 and potentiated these NR4As to transactivate a promoter containing NR4A-binding elements, with this transactivation being, at least in part, dependent on the phosphorylation. This suggests an evolutionarily conserved role for p38 MAPKs in the regulation of NR4As. Thus, p38-regulated gene induction through NR4As appears to function in the dopamine synthesis pathway and may be involved in immune and stress responses.

A clinical study of the prognostic factors for postoperative early recurrence in patients who underwent complete resection for pulmonary adenocarcinoma

PURPOSE

The 2-[F-18]-Fluoro-2-deoxy-D-glucose (FDG) uptake in positron emission tomography (PET) and serum neutrophil/lymphocyte ratio (NLR) are recently noteworthy prognostic factors. We studied the prognostic factor to predict early recurrence after curative resection for pulmonary adenocarcinoma including FDG uptake and NLR.

METHODS

We performed a retrospective review of 23 patients who underwent a complete resection for pulmonary adenocarcinoma. The patients were divided into 2 groups: 19 patients in the disease-free group, and 4 patients in the recurrent group. Clinical and pathological factors concerning the recurrence within 1 year of surgery were analyzed between two groups.

RESULTS

No significant differences between the recurrent group and disease-free group was seen in age, gender, CEA, NLR, CRP, pathological stage, pleural invasion, pathological grading, Ki-67 expression, venous invasion and lymphatic invasion. The SUVmax was significantly elevated in the recurrent group (12.5 ± 2.01 vs. 5.70 ± 3.97, p = 0.0094). Tumor size was significantly larger in the recurrent group (5.58 ± 0.71 vs. 3.62 ± 1.33 cm, p = 0.0058). The first, recurrent sites in 4 patients were brain, in 3 patients; and lung, in 1 patient.

CONCLUSION

Both tumor size and SUVmax are possible predictors of early recurrence after curative resection in patients with pulmonary adenocarcinoma. Although it is impossible to determine the SUVmax as an independent prognostic factor, the SUVmax may be one of the predictors of early hematogenous recurrence in surgically treated pulmonary adenocarcinoma.

[Bronchioloalveolar carcinoma producing CA19-9]

A 76-year-old man, who had underwent radiation for laryngeal cancer 5 years before, was pointed out abnormal pulmonary lesion on computed tomography. The 4.6 cm-sized lesion was seen in the upper lobe of the left lung. Endoscopic brushing cytology revealed adenocarcinoma. The patient was diagnosed as primary lung cancer of T2N0M0, clinical stage IB. Preoperative serum CA19-9 was elevated to 250 U/ml, although other tumor markers were within normal limits. The patient underwent left upper lobectomy with mediastinal lymph node dissection. Histologically, the lesion was diagnosed as well differentiated adenocarcinoma, mucinous subtype of bronchioloalveolar carcinoma (BAC) in World Health Organization (WHO) classification. Immunohistochemistry shows positive for CA19-9 and thyroid transcription factor-1 (TTF-1).

[Three primary cancers of pulmonary cancer, malignant melanoma and esophageal cancer; report of a case]

A 61-year-old man, who had medical history of hepatitis type C, surgery for malignant melanoma of the lower limb, endoscopic mucosal resection for esophageal cancer, was pointed out a pulmonary nodule in the right middle lobe by surveillance computed tomography after 5 years of surgery for melanoma. Pathology of esophageal cancer was squamous cell carcinoma limited in mucosa without lymphatic nor venous invasion. The nodule gradually enlarged and respiratory endoscopic examination could not establish pathological diagnosis. Thoracoscopy-assisted pulmonary biopsy revealed squamous cell carcinoma, and right middle lobectomy with mediastinal node dissection was performed. Histological examination showed moderately differentiated squamous cell carcinoma without lymph node involvement. The stage of lung cancer was T1N0M0, stage IA. Although 9 months have passed since surgery for lung cancer, recurrence of each malignancy has not been detected.

[Multiple nodular pulmonary amyloidosis complicated with Sjögren syndrome]

A 67-year-old woman, who had been treated for Sjögren syndrome and rheumatoid arthritis for 10 years, was consulted for examination of multiple nodular pulmonary nodules. She has been pointed out multiple pulmonary nodules on chest computed tomography (CT) for 7 years, of which the number and the size gradually increased. When visuting our hospital, approximately 20 nodules up to 10 mm in size were noted. Thoracoscopic resection of the nodule was performed and histological diagnosis was amyloid, which was negative for A- and P- component and positive for transthyretin. Neither amyloid deposition in other organs nor abnormal protein in serum and urine was detected. The diagnosis of localized nodular pulmonary amyloidosis was established. As far as our knowledge, this is the 1st report of transthyretin amyloidosis with Sjögren syndrome.

[Assessment of surgical treatment for lung cancer with pericardial or left atrial invasion]

We evaluated surgical results for the patients who underwent pulmonary resection combined with pericardial or left atrial resection due to locally advanced non-small cell lung cancer (NSCLC). Seven patients who underwent pericardial resection (T3 group) and 4 patients who underwent resection of the left atrium (T4 group) were included in this study, and clinical findings and prognosis were evaluated. Eight patients underwent pneumonectomy, and others underwent lobectomy or bilobectomy. Histology of the cancer was squamous cell carcinoma in all patinets. As for pathological node involvement, N0/N1 disease was 72.7% and N2 disease was 27.3%. Induction chemotherapy was performed in 75.0% of T4 group. Adjuvant chemotheraphy was performed in 71.4% of T3 group and 75.0% of T4 group. Five-year-survival was 57.1% in T3 group and 25.0% in T4 group. Five-year-survival was 62.5% in N0/N1 disease and 0% in N2 disease. Statistical significance in prognosis was seen in lymph node status (p = 0.0317). Extended resection of pericardium or left atrium for patients with N2 disease of NSCLC is not recommended. When invasion to pericardium or left atrium is diagnosed during surgery, extended resection should be indicated in patient without N2 metastasis.

[Surgical treated pulmonary metastasis from prostatic cancer; report of a case]

A 74-year-old man who had been treated by endocrine therapy for prostatic cancer for 7 years was pointed out an abnormal shadow on the chest X-ray. Computed tomography showed solitary tumor in the lower lobe of the left lung. Transbronchial lung biopsy revealed pulmonary metastasis form prostatic cancer. Because no other metastatic lesions were detected, the patient underwent surgery for pulmonary lesion. The wedge resection of the left lung was performed. Microscopically, the diagnosis of pulmonary and multiple pleural metastases was established. The pulmonary metastasis without bone nor lymph node metastasis is rare. Pleural metastasis should be considered in case of pulmonary metastasis from prostatic cancer. Surgical indication for pulmonary metastasis from prostatic cancer has to be decided carefully.

Cytocompatibility of calcium phosphate coatings deposited by an ArF pulsed laser

In the current studies, we deposited ultra-thin hydroxyapatite films on a pure titanium substrate by pulsed laser deposition, and we examined the effects of these surfaces on rat bone marrow (RBM) cells. This method allowed deposition of 500-, 2,000-, and 5,000-A-thick hydroxyapatite films. X-ray diffraction showed that the amorphous films recrystallized to a hydroxyapatite crystal structure after annealing. The proliferation of RBM cells was unaffected by the hydroxyapatite films, but osteocalsin and alkaline phosphatase mRNA and protein levels were elevated in cells grown on 2,000- and 5,000-A-thick films. These results indicate that ultra-thin hydroxyapatite films generated by pulsed laser deposition are better at promoting osteogenesis than pure titanium surfaces.

Cytocompatibility of calcium phosphate coatings deposited by an ArF pulsed laser

In the current studies, we deposited ultra-thin hydroxyapatite films on a pure titanium substrate by pulsed laser deposition, and we examined the effects of these surfaces on rat bone marrow (RBM) cells. This method allowed deposition of 500-, 2000-, and 5000-Angstrom-thick hydroxyapatite films. X-ray diffraction showed that the amorphous films recrystallized to a hydroxyapatite crystal structure after annealing. The proliferation of RBM cells was unaffected by the hydroxyapatite films, but osteocalsin and alkaline phosphatase mRNA and protein levels were elevated in cells grown on 2000- and 5000-Angstrom-thick films. These results indicate that ultra-thin hydroxyapatite films generated by pulsed laser deposition are better at promoting osteogenesis than pure titanium surfaces.

[Congenital esophagobronchial fistula treated with thoracoscopic assisted surgery]

A case of congenital esophagobronchial fistula in a 58-year-old woman was described. The patient had presented with repeated attacks of pulmonary infection from her childhood and had a history of recurrent cough after eating or drinking. Preoperative examinations including esophagogram by barium swallow revealed existence of a fistula between the upper thoracic esophagus and the right B3 bronchus. The fistula was recognized as type I of Braimbridge classification. Thoracoscopic assisted fistulectomy and diverticulectomy for esophagobronchial fistula with esophageal diverticulum were performed. The neck of the diverticulum and the fistula were divided with endo-stapling technique. Intraoperative esophagoscopy was found to be useful for the definite localization and complete excision of the fistula and the diverticulum and the avoidance of stenosis of the esophagus. Postoperative course was uneventful. It is to be considered that the present thoracoscopic assisted procedure with intraoperative esophagoscopy can be used as a standard operative procedure for esophagobronchial fistula with esophageal diverticulum.

Hypoxia enhances the expression of plasminogen activator inhibitor-1 in human lung cancer cells, EBC-1

Plasminogen activator inhibitor-1 (PAI-1) is one of the target genes of hypoxia inducible factor-1alpha (HIF-1alpha). Besides being an important physiological regulator of the fibrinolytic system PAI-1 is also involved in cancer invasiveness. HIF-1alpha is expressed in various types of pulmonary cells, but the relation of PAI-1 to HIF-1alpha under hypoxic condition in these cells are not fully elucidated. We, therefore, studied the effect of hypoxia on the expression of PAI-1 in a lung cancer cell line EBC-1. The expression of HIF-1alpha protein in EBC-1 cells was enhanced by hypoxia, and this was associated with increased secretion of PAI-1. Hypoxia did not affect the levels of HIF-1alpha mRNA but enhanced the PAI-1 mRNA. Pretreatment of the cells with MG132, which inhibits the proteasomal degradation of HIF-1alpha, increased the production of PAI-1 under both normoxia and hypoxia. We conclude that hypoxia induces PAI-1 expression, in EBC-1 cells, through the stabilization of HIF-1 complex and this may be related to cancer metastasis.

[A case of squamous cell carcinoma of the lung associated with exophthalmos and hypercalcemia]

A 69-year-old man visited in the department of ophthalmology of this university, complained with exophthalmos. He was pointed out hypercalcemia and transferred to the department of endocrinology. The chest X-ray and thoracic CT showed a large mass in lower lobe of the left lung. Cytological diagnosis of this tumor was squamous cell carcinoma. In clinical examination, serum CA was 12.2 mg/dl in spite of normal level of PTH, calcitonin, 1 alpha, -25 (OH) 2D3 and uric cAMP. On the other hand, PTHrP-intact in serum was 9.8 pmol/l. His thyroid gland had no abnormality in palpation or roentogenological examination. The thyroid functions, thyroglobulin, thyrotropin receptor antibody, thyroid test and microsome test were all in normal limit. From these results, he was diagnosed of lung cancer with humoral hypercalcemia of malignancy and euthyroid "isolated" Graves' ophthalmopathy. Left lower lobectomy with mediastinal lymph node dissection (R 2 a) was done and p-stage was IIIA. After operation, serum Ca decreased in normal level and the exophthalmos was also improved gradually. He was in well until 10 months after operation, and died with multiple lung metastases and hypercalcemia. Exophthalmos was also recurred in his terminal stage. Similar case could not find in literature and some discussion of the literatures was mentioned.

[Preoperative evaluation of the right ventricular function using the pulsed Doppler echocardiogram in the patients scheduled for the elective pulmonary resection]

Preoperative evaluation of the both right ventricular (RV) systolic and diastolic function using the pulsed Doppler echocardiogram were examined for 46 patients scheduled for the pulmonary resection of the pulmonary tumorous lesions. The parameters which included the RV inflow pattern at the tricuspid orifice and the RV ejection flow pattern at the RV outflow tract were obtained by the pulsed Doppler echocardiogram. Following results were obtained. 1) The RV afterload shown by the parameters of the acceleration time (AT, time beginning of RV ejection to peak velocity) were higher in the aged patients, the low FEV 1% populations, and the patients having the deteriorated left ventricular contraction. 2) The RV diastolic dysfunction were present preoperatively in aged patients over the 60 years old. This phenomenon was characterized by a high degree of atrial contraction and an increased ratio of the peak velocity in atrial contraction phase to that in early rapid filling phase (A/E). When we evaluate the RV inflow and ejection Doppler flow patterns after the major lung resection, these findings must be considerable thing.

[A case of mediastinal goiter with hyperthyroidisms]

A 65-years-old woman admitted to the hospital in order to treat of the mediastinal tumor, but she suffered from palpitation, slight fever, sweating, uneasiness, sleeplessness and weightloss. On the physical examination, she was experiencing tachycardia, fevering (37.2 approximately 37.6 degrees C). Skin was moist but had no exophtalmos or neck tumor. Chest X-ray showed an abnormal shadow in the upper mediastinum. On chest CT, a tumor mass (9 x 5 x 4 cm) with cystic regions and scattered calcifications occupied from anterior to posterior mediastinum. The tumor compressed trachea to the left and right brachiocephalic vein and SVC to the right. Lower portion of the tumor intruded into behind of the trachea. Lymph node swelling of mediastinum was also detected. Results of general laboratory examination were within normal limits. Thyroid function test revealed hyperthyroidism; T3U 58%, free T3 24.4 pg/ml, free T4 6.0 ng/dl and thyroglobulin 967 mg/dl, but TSH was < 0.01 microIU/ml. After daily administration of methimazole (300 mg/day) for 4 weeks, thyroid function became to normal level and symptoms of hyperthyroidism was disappeared. The tumor was completely extirpated with right hemithyroidectomy and lymph node dissection under neck colla incision and median sternotomy. Pathological finding of the tumor showed follicular-fetal adenoma of thyroid with hyaloid degeneration and cystic change. There was no finding suspected of Graves' disease. She is well without any complications for 8 months after operation. Some discussion of the literature was mentioned.

[Usefulness of the preoperative MRI for diagnosis and operative method in a case of cor triatriatum]

A case was 6-year-old female diagnosed as the cor triatriatum. The magnetic resonance imaging synchronized at R wave on the electrocardiogram was performed in order to see the abnormal septum in the left atrium. In the horizontal view, the abnormal septum that divides the left atrium into the accessory left atrial chamber and the true left atrium, was well visualized. This septum lied on the vertical portion. Operation was carried out with the approach through the accessory chamber and the fibromuscular membrane were excised. Preoperative imaging of the MRI was useful and helpful for us to reach to a decision of the surgical approach in this patient.

[Emergency surgical salvage for a type A early thrombosed aortic dissection complicated cardiac tamponade in a 80-year-old-patient]

A 80-year-old woman underwent emergency operation for a type A early thrombosed aortic dissection associated with cardiac tamponade. Her preoperative chest CT (not enhanced) showed high density area in the false lumen that indicated early thrombosis and the projection of true lumen at antero-left-lateral portion of ascending aorta that means "ulcer-like projection" called on aortogram. After the relief of the cardiac tamponade by pericardiocenthesis, we emergently performed the graft replacement of the ascending aorta under the extracorporeal circulation combined with selective cerebral perfusion. Her postoperative course was uneventful and satisfactory.

[Autologous blood transfusion in cardiac surgery over 70-year-old patients]

We discussed the problems for autologous blood transfusion particularly in the preoperative blood donation about the patients over 70-year-old who underwent cardiac surgery in contrast with the younger patients. Following results were obtained: 1) Because aged patients have the tendency of anemia before predonation, full storage of blood donation could not be successed. 2 of 8 over 70-year-old patients were able to do the preoperative phlebotomy, and their mean volume were 355 gram as whole blood. On the other hand, 96% patients in younger group were phlebotomized preoperatively, and their mean value of storaged blood volume were 757 gram. 2) As the examinations about the iron-related parameters, not all aged patients were iron deficiency status. Their reticulocyte counts were nearly equal level to the younger group and plasma concentration of erythropoietin were higher in the aged patients than that in the younger group. These results indicate that erythropoiesis in the bone marrow was deteriorated in the aged patients. 3) In aged patients, all of them were required homologous blood transfusion at their perioperative terms. We thought that they have had the anemia before preoperation and our tolerable, allowable level to the postoperative anemia was not lower in the aged patients as against to the younger group. 4) We performed the autologous plasma donation with the membranous plasma separator added to the whole blood donation. It was easy and safe method, and circulatory indices were not changed before and after plasma-separation even in the aged patients. These autologous plasma were usefully administered as the volume expander postoperatively.

Delayed hemolytic transfusion reaction with anti-Jkb erythrocyte antibody after open heart surgery

A patient suffering from delayed hemolytic transfusion reaction with anti-Jkb erythrocyte antibody after open heart surgery is reported on. On preoperation evaluation, a 42-year-old woman who had never been transfused exhibited a negative erythrocyte autoantibody. After the operation of aortic valve replacement and open mitral commisurotomy, she developed a severe hemolytic anemia with a positive rare anti-Jkb erythrocyte antibody on the 14th postoperative day. Precautions are discussed which need to be taken to distinguish delayed hemolytic transfusion reaction from mechanical hemolysis caused by extracorporeal circulation and prostheses.

[A case of malignant thymoma associated with myasthenia gravis, pure red cell aplasia and high serum level of SCC antigen]

We present a case of 43-year-old man with pure red cell aplasia appearing 8 years after thymothymectomy. He underwent an operation and postoperative radiotherapy for malignant thymoma associated with myasthenia gravis in 1983. In 1991 high serum level of SCC antigen was noted and a metastatic tumor was found in the retroperitoneal region. After removal of the tumor pure red cell aplasia developed, which responded to steroid therapy. The serum level of SCC antigen is still abnormally high.

A single amino acid substitution converts cytochrome P450(14DM) to an inactive form, cytochrome P450SG1: complete primary structures deduced from cloned DNAS

Genes for lanosterol 14-demethylase, cytochrome P450(14DM), and a mutated inactive cytochrome P450SG1 were cloned from S. cerevisiae strains D587 and SG1, respectively. A single nucleotide change resulting in substitution of Asp for Gly-310 of cytochrome P450(14DM) was found to have occurred in cytochrome P450SG1. In this protein the 6th ligand to heme iron is a histidine residue instead of a water molecule, which may be the ligand for the active cytochrome P450(14DM). Molecular models of the active sites of the cytochrome P450(14DM) and cytochrome P450SG1 were built by computer modeling on the basis of the known structure of that of cytochrome P450CAM whose crystallographic data are available. The mechanisms which may cause a histidine residue to gain access to the heme iron are discussed.