Subcellular Distribution of BALF2 and the Role of Rab1 in the Formation of Epstein-Barr Virus Cytoplasmic Assembly Compartment and Virion Release

Epstein-Barr virus (EBV) replicates its genome in the nucleus and undergoes tegumentation and envelopment in the cytoplasm. We are interested in how the single-stranded DNA binding protein BALF2, which executes its function and distributes predominantly in the nucleus, is packaged into the tegument of virions. At the mid-stage of virus replication in epithelial TW01-EBV cells, a small pool of BALF2 colocalizes with tegument protein BBLF1, BGLF4 protein kinase, and the cis-Golgi marker GM130 at the perinuclear viral assembly compartment (AC). A possible nuclear localization signal (NLS) between amino acids 1100 and 1128 (C29), which contains positive charged amino acid 1113RRKRR1117, is able to promote yellow fluorescent protein (YFP)-LacZ into the nucleus. In addition, BALF2 interacts with the nucleocapsid-associated protein BVRF1, suggesting that BALF2 may be transported into the cytoplasm with nucleocapsids in a nuclear egress complex (NEC)-dependent manner. A group of proteins involved in intracellular transport were identified to interact with BALF2 in a proteomic analysis. Among them, the small GTPase Rab1A functioning in bi-directional trafficking at the ER-Golgi interface is also a tegument component. In reactivated TW01-EBV cells, BALF2 colocalizes with Rab1A in the cytoplasmic AC. Expression of dominant-negative GFP-Rab1A(N124I) diminished the accumulation of BALF2 in the AC, coupling with attenuation of gp350/220 glycosylation. Virion release was significantly downregulated by expressing dominant-negative GFP-Rab1A(N124I). Overall, the subcellular distribution of BALF2 is regulated through its complex interaction with various proteins. Rab1 activity is required for proper gp350/220 glycosylation and the maturation of EBV. IMPORTANCE Upon EBV lytic reactivation, the virus-encoded DNA replication machinery functions in the nucleus, while the newly synthesized DNA is encapsidated and transported to the cytoplasm for final virus assembly. The single-stranded DNA binding protein BALF2 executing functions within the nucleus was also identified in the tegument layer of mature virions. Here, we studied the functional domain of BALF2 that contributes to the nuclear targeting and used a proteomic approach to identify novel BALF2-interacting cellular proteins that may contribute to virion morphogenesis. The GTPase Rab1, a master regulator of anterograde and retrograde endoplasmic reticulum (ER)-Golgi trafficking, colocalizes with BALF2 in the juxtanuclear concave region at the midstage of EBV reactivation. Rab1 activity is required for BALF2 targeting to the cytoplasmic assembly compartment (AC) and for gp350/220 targeting to cis-Golgi for proper glycosylation and virion release. Our study hints that EBV hijacks the bi-directional ER-Golgi trafficking machinery to complete virus assembly.

Ensembled artificial neural networks to predict the fitness score for body composition analysis

OBJECTIVES

To predict the nutrition and health status of staff and students in Yuan Ze University and select the influential variables from the total body composition variables, which should have similar predictive ability with the whole factors.

DESIGN

Spontaneous and voluntary physical examination.

SETTING

Sanitary and Health Care Section of Yuan Ze University in Taiwan.

PARTICIPANTS

1227 staff and students.

MEASUREMENTS

With the help of Inbody720TM, 139 body composition variables were measured and 60 variables were retained after data pre-processing. An ensembled artificial neural networks (EANN) prediction model was established and seven different methods for assessing variables importance were applied. Besides, classical linear and logistic regression models were developed for comparison with EANN prediction results.

RESULTS

The prediction performance of EANN model was satisfactory (RMSE (train) = 0.2686, RMSE (validation) = 0.2648, RMSE (test) = 0.3492). Since both the actual and simulation fitness score were at the range of 0 to 100, according to rounding off rule, the simulated value was almost the same with actual value. Besides, 12 important variables were obtained by seven methods for quantifying variable importance in EANN, which had similar predictive capability with 60 variables (RMSE (train) = 0.3263, RMSE (validation) = 0.322, RMSE (test) = 0.3226). The linear and logistic regression models results were both evidently worse than EANN results.

CONCLUSION

The results confirm that EANN is appropriate to approximate such a complicated, non-invasive and highly non-linear problem as body composition analysis. It can be helpful for nutritionists to manage and improve the nutrition and health condition of staff and students, by adjusting the 12 most important variables.

Influence of temperature on the ontogenetic expression of neural development-related genes from developing tilapia brain expressed sequence tags

The developing central neural circuits in teleosts are genetically controlled and temperature-initiated. We compiled a list of transcripts expressed in the developing tilapia (Oreochromis mossambicus) brain using expressed sequence tags derived from the developing brain, and investigated genes with thermosensitive ontogenetic expression. Of 1084 clones, 893 were unique genes, 445 of which were known. Fourteen of the latter were neural development-related, and the ontogenetic expression of nine was temperature-influenced. Discs large homolog 5, myelin expression factor 2, plasticity-related protein-2, tsc2 gene product-related genes, and an inhibitor of differentiation protein 2 (Id2) were differentially temperature-influenced according to their developmental stages. Endothelial differentiation-related factor 1, midkine-related growth factor b, and mitogen-activated protein kinase 14b were specifically influenced by elevated temperature, and beta-catenin-like isoform 1 by lower temperature. Neural development-related genes, particularly those with thermosensitive ontogenetic expression, might be important for developing central neural circuits in teleosts.

An open, multi-centre, phase II clinical trial to evaluate the efficacy and safety of paclitaxel, UFT, and leucovorin in patients with advanced gastric cancer

The aim of the study was to evaluate the response rate and safety of weekly paclitaxel (Taxol((R))) combination chemotherapy with UFT (tegafur, an oral 5-fluorouracil prodrug, and uracil at a 1 : 4 molar ratio) and leucovorin (LV) in patients with advanced gastric cancer. Patients with histologically confirmed, locally advanced or recurrent/metastatic gastric cancer were studied. Paclitaxel 1-h infusion at a dose of 100 mg m(-2) on days 1 and 8 and oral UFT 300 mg m(-2) day(-1) plus LV 90 mg day(-1) were given starting from day 1 for 14 days, followed by a 7-day period without treatment. Treatment was repeated every 21 days. From February 2003 to October 2004, 55 patients were enrolled. The median age was 62 years (range: 32-82). Among the 48 patients evaluated for tumour response, two achieved a complete response and 22 a partial response, with an overall response rate of 50% (95% confidence interval: 35-65%). All 55 patients were evaluated for survival and toxicities. Median time to progression and overall survival were 4.4 and 9.8 months, respectively. Major grade 3-4 toxicities were neutropenia in 25 patients (45%) and diarrhoea in eight patients (15%). Although treatment was discontinued owing to treatment-related toxicities in nine patients (16%), there was no treatment-related mortality. Weekly paclitaxel plus oral UFT/LV is effective, convenient, and well tolerated in treating patients with advanced gastric cancer.

Hepatitis B virus reactivation in breast cancer patients undergoing cytotoxic chemotherapy and the role of preemptive lamivudine administration

BACKGROUND

Recent data suggest that hepatitis B virus (HBV) reactivation develops in 41% of breast cancer (BC) patients carrying HBV after chemotherapy. Our study aimed to determine the role of preemptive use of lamivudine in BC patients undergoing chemotherapy.

PATIENTS AND METHODS

The test group consisted of 11 female patients with BC who were seropositive for hepatitis B surface antigen (HBsAg). Of these, 10 patients were treated in an adjuvant setting and one for metastatic disease. Lamivudine was given from the start of chemotherapy and was maintained until 1 month after the last infusion of chemotherapy. The control group consisted of nine historical BC patients carrying HBV and received similar systemic chemotherapy without preemptive lamivudine. Variables including HBsAg, HBV envelope antigen, anti-HBV envelope antibody, serial serum alanine transaminase (ALT), quantitative HBV viral DNA analysis, and HBV-DNA precore promoter and precore sequence were monitored. Test for emergence of mutant strains, notably nucleotide 550, was performed 6 months after the completion of chemotherapy.

RESULTS

All patients tolerated lamivudine well without development of evident HBV reactivation or overt hepatitis. Serum ALT remained unchanged without rebound hepatitis after cessation of chemotherapy and withdrawal of lamivudine. No emergence of lamivudine-selective resistant strain (so-called tyrosine-methionine-aspartate-aspartate mutations) was observed.

CONCLUSIONS

Our results encourage preemptive use of lamivudine for prevention of HBV reactivation in patients who need short-term chemotherapy.

Phase II study of weekly oxaliplatin and 24-h infusion of high-dose 5-fluorouracil and folinic acid in the treatment of advanced gastric cancer

To investigate the efficacy and safety of combining weekly oxaliplatin with weekly 24-h infusion of high-dose 5-fluorouracil (5-FU) and folinic acid (FA) in treatment of patients with advanced gastric cancer. Patients with histologically confirmed, locally advanced or recurrent/metastatic gastric cancer were studied. Oxaliplatin 65 mg m⁻² 2-h intravenous infusion, and 5-FU 2600 mg m⁻² plus FA 300 mg m⁻² 24-h intravenous infusion, were given on days 1 and 8, repeated every 3 weeks. Between January 2001 through January 2002, 55 patients were enrolled. The median age was 64 years (range: 22–75). In all, 52 patients (94.5%) had recurrent or metastatic disease and three patients had locally advanced disease. Among 50 patients evaluable for tumour response, 28 patients achieved partial response, with an overall response rate of 56% (95% confidence interval (CI): 41.8–70.3%). All 55 patients were evaluated for survival and toxicities. Median time to progression and overall survival were 5.2 and 10.0 months, respectively, during median follow-up time of 24.0 months. Major grades 3–4 toxicities were neutropenia in 23 cycles (7.1%) and thrombocytopenia in 16 cycles (5.0%). Treatment was discontinued for treatment-related toxicities in nine patients (16.4%), of whom eight were due to oxaliplatin-related neurotoxicity. One patient (1.8%) died of neutropenic sepsis. This oxaliplatin-containing regimen is effective in the treatment of advanced gastric cancer. Except for neurotoxicity that often develops after prolonged use of oxaliplatin, the regimen is well tolerated.

Suppurative salmonella thyroiditis in a patient with chronic lymphocytic leukemia

We describe an 82-year-old man with undiagnosed chronic lymphocytic leukemia (CLL) who presented with acute swelling of the thyroid goiter. Subsequent thyroid aspirate and blood culture yielded group B Salmonella thyroid abscess with septicemia. Infectious complications are the major cause of morbidity and mortality in patients with CLL since most of them can be timely detected and few can arise from innocent-looking lesions.

Stenotrophomonas maltophilia septicemia with pyomyositis in a chemotherapy-treated patient

Pyomyositis is a rare complication of chemotherapy. A 35-year-old male patient with myelodysplastic syndrome developed Stenotrophomonas maltophilia bacteremia shortly after chemotherapy, and Stenotrophomonas maltophilia-related pyomyositis was encountered after recovery from neutropenia. He recovered completely after surgical drainage and a protracted course of antibiotic treatment. It is postulated that subclinical myopathy, immunosuppression secondary to the malignancy, or chemotherapeutic drugs may predispose to pyomyositis. Early recognition of this unusual complication in a cancer patient undergoing chemotherapy can prevent further catastrophes.

The high value of high-resolution computed tomography in predicting the activity of pulmonary tuberculosis

SETTING

A 2500-bed medical centre in southern Taiwan.

OBJECTIVE

To study the clinical value of high-resolution computed tomography (HRCT) in predicting the activity of pulmonary tuberculosis (TB).

DESIGN

HRCTs were performed prospectively in 148 patients whose chest radiographs (CXRs) showed highly suspicious signs of pulmonary TB, predominantly upper lung field infiltration. The HRCT findings, interpreted independently by a pulmonologist and a radiologist, were used to predict the activity of pulmonary TB.

RESULTS

Pulmonologist-interpreted and radiologist-interpreted HRCTs showed high sensitivity (both 93%), specificity (83 vs. 88%), accuracy (86 vs. 90%), positive predictive values (76 vs. 83%) and negative predictive values (both 95%). Kappa statistic indicates good inter-reader agreement.

CONCLUSION

HRCT has a high value in predicting the activity of pulmonary TB. It is a useful tool in this regard when a patient with suspected pulmonary TB lacks microbiologic proof, when clinical condition makes invasive diagnosis impossible or when a patient has completed anti-tuberculosis treatment with no compatible unequivocal CXR.

Pseudothrombocytopenia associated with infectious mononucleosis

A 22-year-old man was hospitalized for assessment of thrombocytopenia and fever. Examination showed that he had infectious mononucleosis and moderately severe thrombocytopenia that was asymptomatic. Examination of blood smears revealed that the thrombocytopenia was caused by the clumping of platelets. We made a diagnosis of ethylenediaminetetraacetic acid-dependent pseudothrombocytopenia after excluding other infectious mononucleosis-related mechanisms of thrombocytopenia. When the patient recovered from infectious mononucleosis 2 months later, his thrombocytopenia improved, and no platelet clumping in peripheral blood smears was noted. Ethylenediaminetetraacetic acid-dependent pseudothrombocytopenia should always be considered as a possible cause of reported low platelet counts, even in patients with infectious mononucleosis and splenomegaly.

Reactivation of precore mutant hepatitis B virus in chemotherapy-treated patients

BACKGROUND

A point mutation from G to A at nucleotide (nt) 1896 of the precore region of hepatitis B virus (HBV) DNA has been shown to be associated with fulminant and severe hepatitis. Further studies have suggested that this point mutation, together with additional mutations in the precore promoter, is probably linked to the reactivation of HBV in patients undergoing cytotoxic chemotherapy. Taiwan is an area with a high prevalence of HBV where hepatitis B flare-up has become a serious problem of HBV carriers who must rely on chemotherapy to treat their diseases. The purpose of this study was to examine if nt 1896 mutation was also present in Chinese patients in Taiwan who developed severe liver disease after chemotherapy. MATERIALS AND METHODS. Thirteen HBV carrier patients, including eight patients with lymphoma, two with germ cell tumors, two with breast carcinomas, and one with acute myeloid leukemia, received chemotherapy in the authors' hospital from February 1994 to May 2000. They all received steroid-containing regimens or antiemetics during chemotherapy. These patients were monitored closely for the development of severe hepatitis during or after chemotherapy. Their sera were harvested at different times for direct sequencing of the polymerase chain reaction products of the precore region of HBV DNA.

RESULTS

Six of the 13 patients developed severe hepatitis with a fulminant course during or after the completion of chemotherapy. A point mutation from G to A at nt 1896 was detected in five of these six patients. Among those five patients, four had additional precore mutations. The other patient did not have the nt 1896 mutation but had mutations at nt 1835 (A to C). None of the other seven patients lacking the precore nt 1896 mutation developed severe hepatitis flare-up. One of those seven patients who developed moderate elevation of alanine aminotransferase (ALT) without hyperbilirubinemia did have precore mutations other than nt 1896. None of the other six patients had mutations over the precore region.

CONCLUSIONS

Nucleotide mutation of the precore region, notably at position 1896, is associated with reactivation of HBV with a fulminant course during or after chemotherapy. The current data, together with other investigators' findings, suggest that patients who are HBV carriers with HBV envelope antigen (HBeAg) (-)/anti-HBV envelope antibody (Anti-HBe)(+) status should be assayed to determine if they carry mutant HBV before chemotherapy. Prophylactic use of lamivudine is strongly recommended for patients who carry mutant HBV at precore region, especially at nt 1896 (G to A), before and during chemotherapy.

Reactivation of precore mutant hepatitis B virus in chemotherapy-treated patients

BACKGROUND

A point mutation from G to A at nucleotide (nt) 1896 of the precore region of hepatitis B virus (HBV) DNA has been shown to be associated with fulminant and severe hepatitis. Further studies have suggested that this point mutation, together with additional mutations in the precore promoter, is probably linked to the reactivation of HBV in patients undergoing cytotoxic chemotherapy. Taiwan is an area with a high prevalence of HBV where hepatitis B flare-up has become a serious problem of HBV carriers who must rely on chemotherapy to treat their diseases. The purpose of this study was to examine if nt 1896 mutation was also present in Chinese patients in Taiwan who developed severe liver disease after chemotherapy. MATERIALS AND METHODS. Thirteen HBV carrier patients, including eight patients with lymphoma, two with germ cell tumors, two with breast carcinomas, and one with acute myeloid leukemia, received chemotherapy in the authors' hospital from February 1994 to May 2000. They all received steroid-containing regimens or antiemetics during chemotherapy. These patients were monitored closely for the development of severe hepatitis during or after chemotherapy. Their sera were harvested at different times for direct sequencing of the polymerase chain reaction products of the precore region of HBV DNA.

RESULTS

Six of the 13 patients developed severe hepatitis with a fulminant course during or after the completion of chemotherapy. A point mutation from G to A at nt 1896 was detected in five of these six patients. Among those five patients, four had additional precore mutations. The other patient did not have the nt 1896 mutation but had mutations at nt 1835 (A to C). None of the other seven patients lacking the precore nt 1896 mutation developed severe hepatitis flare-up. One of those seven patients who developed moderate elevation of alanine aminotransferase (ALT) without hyperbilirubinemia did have precore mutations other than nt 1896. None of the other six patients had mutations over the precore region.

CONCLUSIONS

Nucleotide mutation of the precore region, notably at position 1896, is associated with reactivation of HBV with a fulminant course during or after chemotherapy. The current data, together with other investigators' findings, suggest that patients who are HBV carriers with HBV envelope antigen (HBeAg) (-)/anti-HBV envelope antibody (Anti-HBe)(+) status should be assayed to determine if they carry mutant HBV before chemotherapy. Prophylactic use of lamivudine is strongly recommended for patients who carry mutant HBV at precore region, especially at nt 1896 (G to A), before and during chemotherapy.

Adult lymphoblastic lymphoma in Taiwan: an analysis of treatment results of 26 patients

Lymphoblastic lymphoma (LBL) frequently affects young adults and usually presents with a mediastinal mass as well as bone marrow involvement. Although the frequency of LBL in the Far East is higher than that of Western countries, no reports regarding treatment of this disease have as yet been reported. We herein report our treatment experience and verify the efficacy of the Stanford/Northern California Oncology Group (NCOG) protocol for this disease and recommend treatment strategies for LBL patients. We retrospectively reviewed the medical records of adult LBL patients treated in our hospital from 1986 to 1996. Twenty-seven patients were diagnosed to have LBL. These patients' ages ranged from 17 to 73 years old with a median of 23. Nineteen patients had an initial stage IV disease. Of the 23 cases in which immunological studies were performed, 20 proved to be of T cell lineage, 1 of B cell type, and the other 2 lacked both T and B markers. Three major chemotherapeutic regimens including prednisone, methotrexate, doxorubicin, cyclophosphamide, etoposide-mechlorethamine, vincristine, procarbazine, prednisone (ProMACE-MOPP), cyclophosphamide, hydroxydaunomycin, vincristine, prednisone (CHOP), and the Stanford/NCOG protocol were used to treat 3, 6, and 15 patients, respectively. Two other patients were treated with two different chemotherapeutic regimens, respectively. One patient was excluded for analysis because of initial treatment by surgery. The complete response (CR) rates with ProMACE-MOPP, CHOP, and the Stanford/NCOG regimens were 0%, 17%, 80% and median overall survival 9, 8.5, and 15 months, respectively. Five patients with stage II-III diseases achieved long-term disease-free survival of 11-36 months with the Stanford/NCOG protocol with a median follow-up of 24 months. Four patients in late stage or relapse received allogeneic bone marrow transplantation (BMT). Two of them obtained long-term disease-free survival. Two other patients in CR were treated with high-dose chemotherapy (HDCT) supported with autologous BMT and peripheral blood stem cell transplantation (PBSCT), respectively. The patient receiving HDCT with autologous PBSCT died of LBL relapse 6 months after transplantation. The other patient undergoing HDCT with autologous BMT died of fulminant hepatitis 5.5 months after transplantation. The median overall survival of all these 26 patients was 12 months. B symptoms and treatment without the Stanford/NCOG protocol were found to have significantly negative impacts on both patients' overall and progression-free survivals. Our results suggest that the Stanford/NCOG protocol may be an effective chemotherapy for adult LBL and may provide long-term remission for patients in an early stage of disease. For those patients with LBL in an advanced stage or in relapse, HDCT with allogeneic or autologous BMT is probably the treatment of choice.

Impact of open lung biopsy for undiagnosed pulmonary infiltrates in patients with hematological malignancies

Pulmonary complications are frequently encountered in patients with hematological malignancy. The optimal therapeutic decision including open lung biopsy (OLB) for such patients is uncertain. We herein examine the clinical impact of OLB on these patients. Seven patients with progressively diffuse pulmonary infiltrates despite aggressive medical treatment were examined. The underlying diseases, prior treatment for presumptive pneumonia, the change in therapeutic approach after operation, and clinical outcome were reviewed retrospectively. Diffuse pulmonary infiltrates were caused by infection in two patients and by noninfectious etiology such as alveolar proteinosis, idiopathic interstitial pneumonitis, leukemic involvement, and drug-induced alveolar damage in the others. Four patients who had serious underlying hematologic diseases such as myelodysplastic syndrome, acute and chronic myeloid leukemia, and T cell lymphoma died. Three patients with acute lymphoid leukemia survived. In two of these three, change of therapeutic strategies after OLB was created for the survival. OLB in patients with hematological malignancy may be useful in selected patients with a treatable hematologic disease who have treatable underlying causes of the pulmonary infiltrate.

Autologous peripheral blood stem cell transplantation for patients with malignancies: the Tri-Service General Hospital experience

BACKGROUND

High-dose chemotherapy/radiotherapy followed by autologous peripheral blood stem cells transplantation (APBSCT) can be used to treat chemosensitive malignant diseases. We retrospectively studied the APBSCT treatment efficacy and safety of patients at Tri-Service General Hospital (TSGH).

METHODS

From January 1994 to March 2000, 11 patients were treated with high doses of chemotherapy/radiotherapy followed by APBSCT. Nine patients were male and 2 were female. The median age was 26 years, with a range of 21 to 51. There were 7 acute myeloid leukemia (AML), 3 non-Hodgkin's lymphoma (NHL) and 1 ovarian cancer. All patients received both chemotherapy and granulocyte-colony stimulating factor to mobilize hematopoietic stem cells, and the most commonly used conditioning regimen was combined chemotherapy with Busulfan and Cyclophosphamide.

RESULTS

The median numbers of infused mononuclear and CD34+ cells were 3.19 x 10(8)/kg and 9.2 x 10(6)/kg, respectively. Nine of the 11 patients engrafted successfully, but 2 patients with AML failed to engraft. The median times of WBC recovery (ANC > or = 500/uL) and platelet recovery (> or = 20 x 10(3)/uL) were 13 and 16 days, respectively. Four patients with AML survived after APBSCT and two of them were alive and disease-free for 36 and 51 months, respectively. One patient with AML and 3 patients with NHL died of relapse, and one patient with ovarian cancer was alive but with disease at 50 months.

CONCLUSIONS

For patients with AML, APBSCT may be an alternative, safe and useful treatment modality. Further strategies for reducing relapse in lymphoma patients merit further investigation.

[Factors related to post-treatment marital adjustment in women with breast cancer]

The purpose of this study was to explore post-treatment marital adjustment and related factors in women with breast cancer. The variables include characteristics of illness, pre- and post-treatment marital adjustment, as well as depression. Subjects were recruited by convenience sampling from two medical centers and one community hospital in the Taipei metropolitan area. A total of 119 married women who had received surgery for breast cancer were interviewed with structured questionnaires in a private space. The results showed no difference between marital adjustment pre- and post-treatment. A significant decrease in physical aspects of marriage satisfaction and a significant increase in both psychological and social aspects of marriage satisfaction post-treatment were demonstrated. However, stepwise regression analyses found that the most important predictor of post-treatment marital adjustment is pre-treatment adjustment. Such variables as post-morbid duration, stage of cancer, and different treatment modalities could also predict post-treatment marital adjustment. The results suggest that medical staff should encourage breast cancer patients to face their post-treatment marital status positively. The impact on physical aspects of marriage satisfaction of the breast cancer treatment should not be overlooked. Moreover, an assessment of ovarian function, sexual function, depression, and marital adjustment should be emphasized in women with breast cancer.

Acute respiratory distress syndrome following intrathecal methotrexate administration: a case report and review of literature

Acute Respiratory distress syndrome (ARDS) is a rare complication following intrathecal (IT) injection of methotrexate (MTX) in adult acute lymphoblastic leukemia (ALL) patients. A 19-year-old man with ALL developed strikingly acute respiratory failure during central nervous system (CNS) prophylaxis with IT MTX administration and cranial irradiation. Histopathologic study of the lungs revealed a pattern of diffuse alveolar damage with interstitial cellular infiltration. His symptoms were relieved soon following treatment with corticosteroids and the pulmonary infiltrates resolved gradually. Pulmonary symptoms did not recur as he was continuously treated with oral corticosteroids.

Lymphoma of bone with initial presentation as a calvarial mass

A 21-year-old man was examined for a right frontal skull mass that had been present for 4 months. Excision biopsy of the mass revealed diffuse large B-cell lymphoma. Subsequent studies showed right preauricular lymphadenopathy but no systemic involvement. The patient was treated with six courses of CHOP (cyclophosphamide, adriamycin, vincristine, and prednisolone) with adjuvant whole brain irradiation and achieved a complete remission.

Scrub typhus-associated hemophagocytic syndrome

A patient was admitted to our hospital with fever of unknown origin, lymphadenopathy and moderate anemia. The diagnosis of scrub typhus (tsutsugamushi disease) was established on specific serologic demonstration of antibodies to the cross-reacting proteins OX-K antigen and reaffirmed by successful treatment with doxycycline. The diagnosis of hemophagocytic syndrome (HPS) was made on the cytologic findings of many histiocytes containing phagocytosed blood cells in the marrow aspirate. The hemophagocytosis phenomenon disappeared after the scrub typhus was successfully treated, thus suggesting the relationship between scrub typhus and hemophagocytosis. In a patient with rickettsial diseases including scrub typhus, associated with HPS, it is important to understand the relationship between the two disorders since the prognosis for HPS, if untreated, is very poor.

Pulmonary lymphangioleiomyomatosis in a 29-year-old woman with bilateral spontaneous pneumothorax: case report

Pulmonary lymphangioleiomyomatosis is a rare, progressive and fatal interstitial lung disease that affects women of child-bearing age. It is characterized by the nonneoplastic proliferation of atypical smooth muscle cells around lymphatics, venules, and bronchioles. Patients with pulmonary lymphangioleiomyomatosis most commonly present with exertional dyspnea and a cough. Pneumothorax is almost always found on the initial chest radiograph. We report a case of a 29-year-old woman who presented with abrupt right chest pain and progressive dyspnea. Physical examination in the emergency department was significantly diminished breath sounds over the right lung, and a chest X-ray revealed a right-sided pneumothorax. She required a chest tube for complete lung re-expansion. On the sixth day of admission, left-sided pneumothorax occurred and another chest tube was inserted. She underwent high-resolution computed tomography of the thorax with the findings of numerous cysts evenly distributed throughout the parenchyma of both lungs. Bilateral thoracotomy with lung biopsies and pleurodesis were performed and the surgical findings confirmed the presence of multiple, small, pink-colored cystic lesions on the surfaces of both lungs. Pathological examination showed the characteristic findings of pulmonary lymphangioleiomyomatosis.

Cyclosporine-induced encephalopathy in a patient with relapsed acute myeloid leukemia treated with unrelated allogeneic bone marrow transplantation

Cyclosporine (CSP) is the most frequently used immunosuppressive agent for prevention of graft versus host disease (GVHD) in allogeneic bone marrow transplantation (BMT). Some adverse effects such as hepatic and renal toxicity have been frequently encountered, but central nervous system (CNS) toxicity caused by CSP is rare. We report an adult male patient with acute myeloid leukemia who developed CSP-induced encephalopathy under treatment for allogeneic BMT from an unrelated donor. Methotrexate and CSP were used for GVHD prophylaxis. Leukocyte and platelet engraftment were successfully achieved on days 21 and 24 after BMT, respectively. Abrupt onset of mental confusion and disorientation occurred on day 25, followed by a generalized tonic clonic seizure and consciousness disturbance. The whole blood CSP level was 160.65 ng/mL. Magnetic resonance (MR) imaging revealed high signal intensities in the bilateral occipital lobes with predominant involvement of the cortical areas. The patient recovered from the CNS toxicity, but with slight memory impairment, 6 days after CSP was discontinued. When patients receiving CSP treatment for allogeneic BMT develop mental confusion, consciousness disturbance, or seizure, CSP-induced CNS toxicity should be taken into consideration.

Epstein-Barr virus early ribonucleic acids as a diagnostic adjunct for relapsed metastatic tumors in patients with cured primary undifferentiated nasopharyngeal carcinoma

PURPOSE

Epstein-Barr virus (EBV) has been consistently shown to be associated with undifferentiated nasopharyngeal carcinoma (NPC). In this article, the authors attempt to detect Epstein-Barr virus in distant relapsed metastatic sites in undifferentiated NPC patients with cured primary cancer.

MATERIALS AND METHODS

In situ hybridization (ISH) technique is a reliable method to detect EBV early RNAs (EBERs) within NPC cells. We used a nonisotopical ISH technique to examine the presence of EBERs in paraffin-embedded tissues obtained from 1 paired specimen of primary NPC and its metastatic counterpart at liver and 2 metastatic specimens of retroperitoneal lymph nodes and bone.

RESULTS

All the primary lesions and the metastatic tumors of NPC with undifferentiated histology contained EBERs that could be clearly detected in the nuclei of cancer cells.

CONCLUSIONS

This article shows that EBERs can be successfully detected in cells of the distant relapsed metastatic sites. These results suggest that this nonisotopical ISH method of EBERs can be potentially used to diagnose NPC patients developing distant relapsed metastatic lesions with cured primary cancer early. It can offer quick information as to institute suitable salvage chemotherapy for these patients.

Cerebral dural sinus thrombosis in acute lymphoblastic leukemia with early diagnosis by fast fluid-attenuated inversion recovery (FLAIR) MR image: a case report and review of the literature

Cerebral dural sinus thrombosis (CDST) is a very rare complication of acute lymphoblastic leukemia (ALL) in adult patients. A 23-year-old man with ALL developed dizziness, headache, diplopia, limb weakness, and a sensation of fullness in his head after his second induction chemotherapy with doxorubicin, prednisolone, and vincristine. Examinations of the peripheral blood, bone marrow, and cerebrospinal fluid showed no recurrent leukemic cells. Magnetic resonance (MR) imaging of the brain disclosed unexpected CDST at the left transverse sinus, which was seen only on the fast fluid-attenuated inversion recovery (FLAIR) sequence. His symptoms were relieved soon after treatment with heparin. MR imaging with FLAIR performed a second time 7 days later showed complete disappearance of the thrombosis. The patient was treated continuously with oral anticoagulant therapy and the symptoms did not recur. CDST can be diagnosed in its early phase by MR studies with FLAIR images. Anticoagulant therapy can be administered safely without precipitating the occurrence of infarction hemorrhage at such an early stage of CDST.

Acute lymphoblastic leukemia in young adults: two chemotherapeutic protocols for the treatment of 46 patients

BACKGROUND

Acute lymphoblastic leukemia (ALL) in adults has a very poor prognosis. Many chemotherapeutic protocols have been designed to try to improve treatment results for adult ALL. Two chemotherapeutic protocols were used to treat young adult ALL patients in our institute and treatment results are reported.

METHODS

From 1984 through 1997, 46 young adult patients with ALL were treated. There were 43 males and three females. Their ages ranged from 16 to 38 years, with a median of 24 years. Thirty-two patients (group A) received a four-week conventional induction regimen with daunomycin, vincristine, prednisolone, and L-asparaginase, followed by prophylaxis of the central nervous system (CNS) with intrathecal methotrexate and cranial irradiation, as well as maintenance therapy with oral 6-mercaptopurine and methotrexate. Fourteen patients (group B) received the modified protocol of the German multicenter trial for adult ALL (GMALL) with a two-phase induction regimen, CNS prophylaxis and maintenance therapy.

RESULTS

In group A, 25 of 32 patients achieved complete remission (CR), three obtained partial remission and four died of treatment-related complications during induction therapy. The median duration of remission (DR) was 12 months (range, 3-39 months) and the median overall survival time (OST) was 13 months (range, 0.5-50 months). Of the 25 patients who achieved CR, 21 relapsed and died. In group B, 11 of 14 patients obtained CR and three died of leukopenia-related infectious complications during induction. The median DR was 12 months (range, 8-37 months) and the median OST was 15 months (range, 0.5-39 months). During follow-up, 10 of 11 patients relapsed from ALL and died. Only one patient who received allogeneic bone marrow transplantation first CR is still alive. No statistical differences between the two groups were noted in terms of CR rate, DR (p = 0.87) and OST (p = 0.34). However, the the GMALL protocol had during the significantly more hematologic toxicity during induction therapy.

CONCLUSIONS

Our results suggest that young adult ALL is a disease with a very poor prognosis and conventional chemotherapy is not adequate for its treatment. The notion that GMALL protocol is better than conventional therapy in the treatment of adult ALL cannot be justified by our data.

Adrenal insufficiency caused by primary aggressive non-Hodgkin's lymphoma of bilateral adrenal glands: report of a case and literature review

A 64-year-old woman was hospitalized because of poor general condition, gastrointestinal upset, unexplained fever, electrolyte imbalances, and an incidental finding of bilateral huge adrenal masses on computerized tomography (CT) of the abdomen. Non-Hodgkin's lymphoma (NHL) of B-cell origin was proven by ultrasound-guided aspiration biopsy of the left adrenal gland. Meanwhile, primary adrenal insufficiency was confirmed by her low serum cortisol level, high ACTH level, and inadequate adrenal response to the rapid ACTH stimulation test. The diagnosis of primary adrenal NHL was supported by detailed physical examinations, bone marrow examination, and such imaging studies as CT scan and sonography. She received three courses of chemotherapy with cyclophosphamide, vincristine, and prednisolone and there was an initial transient response, but she died of sepsis and progression of NHL three and a half months later.

Mandibular mass as the presenting manifestation of IgM myeloma in a 22-year-old man

We report here the youngest known IgM myeloma patient to have presented with a mandibular mass. A 22-year-old Chinese man sought medical attention due to a mass over his right mandible that had been growing progressively for 6 months. A solitary osteolytic lesion in the right mandible was identified radiologically. Incisional biopsy revealed the presence of plasma cells of monoclonal origin, as evidenced by the exclusively positive staining of the kappa light chain. The diagnosis of multiple myeloma with mandibular involvement was confirmed by bone marrow examination. Further tests, including immunoglobulin electrophoresis and assay of the serum levels of kappa and lambda light chains, demonstrated that his myeloma was of the IgM, kappa subtype. The patient achieved a nonsustained partial response to six courses of melphalan and prednisolone therapy and palliative radiotherapy.

Acquired hemophilia A: report of two cases

Two patients who presented with active bleeding and were diagnosed with acquired hemophilia A (AHA) are reported herein. One was a 27-year-old woman who experienced spontaneous oozing from an episiotomy wound six days after her second normal delivery. Bleeding became progressively worse, despite treatment with primary sutures and curettage of the uterus at a local hospital. She underwent emergency exploratory laparotomy because of intra-abdominal bleeding, during which perforations of the uterus were discovered. Unremitting bleeding from the surgical wound occurred after surgery. The patient was finally diagnosed with AHA when Factor VIII (FVIII) inhibitor (titer, 19 Bethesda units (BU)/ml) was detected in her plasma. She died of refractory hemorrhaging, despite intensive treatment with Factor IX concentrate infusion and cyclophosphamide therapy. The second patient was a 22-year-old man who sustained spontaneous and recurrent intramuscular hemorrhage in the right thigh for one month. Laboratory studies including complete blood count, biochemical evaluation, coagulation screening and immunologic assays were all within normal limits, except for a prolonged activated partial thromboplastin time. Idiopathic AHA was diagnosed after the detection of plasma FVIII inhibitor with a concentration of 5.9 BU/ml. The patient's coagulopathy was successfully managed with plasma exchange and subsequent treatment with oral prednisolone and cyclophosphamide.

Association between Epstein-Barr virus and Burkitt's lymphoma in Taiwan

BACKGROUND

The association between Epstein-Barr virus (EBV) and Burkitt's lymphoma (BL) in Taiwan is not clear. In this study, the authors attempted to determine the frequency of the occurrence of EBV infection in patients with BL in Taiwan.

METHODS

A retrospective study was performed using a nonisotopic in situ hybridization technique to detect the presence of EBV-encoded small RNAs (EBERs) in paraffin embedded BL tissues. Tissues of other types of B-cell non-Hodgkin's lymphoma (NHL) were used as controls. Immunohistochemical staining was performed to examine the presence of an EBV-encoded protein, latent membrane protein (LMP), and p53 in specimens.

RESULTS

EBERs were detectable in 10 of 18 BL specimens. It was present in the cervical lymph nodes (LNs) in six of the seven cases of cervical tumors, in the maxillary region in one case, in one of two cases of axillary LNs, and in the abdominal tumors in two of the seven cases of intraabdominal disease. EBER positive cells were diffusely present in all tumors except in one abdominal BL, in which only a few EBER positive cells were scattered in a small part of the tumor. EBER positive cells were not detected in the case with BL in an inguinal LN and in the seven cases with intraabdominal tumors. Immunohistochemical studies showed that LMP and p53 were expressed in 3 and 4 of the 18 cases, respectively. In another 20 NHLs in peripheral LNs, EBERs were detectable in only 1 case of diffuse large cell histology with numerous reactive T cells in which only large tumor cells expressed EBERs and LMP. EBERs were not detected in any of the ten cases of extranodal NHL.

CONCLUSIONS

In Taiwan, EBV is frequently associated with BL occurring outside the abdomen but rarely with intraabdominal BL. The overall association between EBV and BL in Taiwan is intermediate compared with other regions of the world. These results support the theory that the frequency of EBV associated with BL is influenced by the endemicity of EBV and/or the socioeconomic status of a country.

Cytology of fine needle aspirates of primary extragonadal germ cell tumors

OBJECTIVE

To describe the characteristic cytologic features of fine needle aspirates (FNAs) of primary extragonadal germ cell tumors (PEGCTs).

STUDY DESIGN

Thirteen patients with PEGCTs, including 2 seminomas, 2 mixed germ cell tumors, 3 immature teratomas, 1 choriocarcinoma and 5 yolk sac tumors (YSTs) were studied. The final diagnosis of PEGCT in all cases was established by histologic examination of the tumor tissues. Fine needle aspiration was done on either the primary tumor or metastatic foci. The aspirates were stained with one of the Romanovsky stains and Papanicolaou stain.

RESULTS

Each type of PEGCT has its own morphologic characteristics. In seminoma, the tumor cells are large and noncohesive, with one to several distinct nucleoli; some lymphocytes are also present. YSTs show many pleomorphic cells with vacuoles in the cytoplasm and nuclei; tumor cells frequently aggregate in a microglandular or papillary pattern. Choriocarcinoma consists of syncytiotrophoblasts and cytotrophoblasts. The former are very large cells with eosinophilic cytoplasm, one to several nuclei and distinct nucleoli; the latter are medium-sized cells with vacuolated, basophilic cytoplasm and eccentric nuclei. Immature teratomas are composed of a mixture of cell types, including elongated epithelioid cells, mesenchymal cells and many large, naked, amorphous nuclei with a homogeneous chromatin pattern. Diagnosis of mixed germ cell tumor is difficult but can be made if two or more subtypes of tumor cells are observed in the FNA.

CONCLUSION

Cytologic examination of FNAs of primary or metastatic lesions of PEGCTs, stained either with Romanovsky or Papanicolaou stain, is of diagnostic value for such diseases. The use of immunochemistry can help to confirm the cytologic impression.

All-trans retinoic acid decreases susceptibility of a gastric cancer cell line to lymphokine-activated killer cytotoxicity

All-trans retinoic acid (RA) was previously shown to regulate the growth of gastric cancer cells derived from the cell line SC-M1. This study was designed to investigate the effect of RA on the sensitivity of SC-M1 cells to lymphokine-activated killer (LAK) activity. RA at the concentration range of 0.001-10 microM was shown to induce SC-M1 cells to exhibit resistance to LAK activity in a dose-dependent manner. A kinetics study indicated that a significantly increased resistance was detected after 2 days of co-culturing SC-M1 cells with RA and reached a maximum after 6 days of culture. Similar results were obtained from two other cancer cell lines: promyelocytic leukaemia HL-60 and hepatic cancer Hep 3B. A binding assay demonstrated that the binding efficacy between target SC-M1 cells and effector LAK cells was not altered by RA. Flow cytometric analyses revealed that RA exhibited no effect on the expression of cell surface molecules, including HLA class I and class II antigens, intercellular adhesion molecule-1 and -2, and lymphocyte function antigen-3. Cell cycle analysis revealed that culture of SC-M1 cells with RA resulted in an increase in G0/G1 phase and a decrease in S phase, accompanied by a decrease in cyclin A and cyclin B1 mRNA as determined by Northern blot analysis. Additionally, RA was shown to enhance the expression of retinoic acid receptor alpha (RAR alpha) in SC-M1 cells, and to have no effect on the expression of RARbeta or RARgamma. Taken together, these results indicate that RA can significantly increase gastric cancer cells SC-M1 to resist LAK cytotoxicity by means of a cytostatic effect through a mechanism relating to cell cycle regulation. The prevailing ideas, such as a decrease in effector to target cell binding, a reduced MHC class I antigen expression or an altered RARbeta expression, are not involved.

Imprint cytology of nasopharyngeal biopsies

OBJECTIVE

To use an instant cytologic diagnostic method to examine touch imprints of nasopharyngeal (NP) biopsies. This method aimed to ensure the adequacy of biopsied specimens for histologic examination. This paper describes the morphologic findings of NP lesions examined by this method.

STUDY DESIGN

Imprints were made from NP biopsies from patients suspicious for nasopharyngeal carcinoma (NPC). These imprints were air dried, stained with Diff-Quik and examined immediately. The adequacy of the specimens was assessed, and the findings of the imprints were interpreted as positive-, negative- or suspicious for NPC. Repeat biopsies and cytologic studies were done as indicated. In selected cases, immunocytochemical staining was done to identify cells on the imprints. Histologic examination of the biopsied specimens served as the control.

RESULTS

With this method we could interpret the imprints within five minutes of their receipt and determine if repeat biopsy was needed. In benign lesions, the imprints often contained many cells, most mature and reactive lymphocytes. These cells and the numerous lymphoglandular bodies (fragments of lymphoid cytoplasm) intermingled with the ciliated and squamous epithelial cells. In cases of NPC, the appearance was discrete, or clusters of, carcinoma cells or naked nuclei. They were less cellular than those of benign lesions. The lymphocytes were markedly depleted. Cells of dubious lineage were identified by the additional use of immunocytochemical studies.

CONCLUSION

Cytologic examination of imprints of NP biopsies helps to determine the adequacy of the specimen for histologic examination. It is a rapid, practical method with high diagnostic accuracy.

Examination of pericardial effusions by cytology and immunocytochemistry

BACKGROUND

Cytologic examination of pericardial effusions (PE) has been uncommonly reported in the literature. Fewer reports have studied the role of immunocytochemistry in diagnosis of PE. We described our experience, according to cytologic examination and immunocyto-chemical staining of PE.

METHODS

Over a four-year period, 50 PE specimens from 36 patients were examined cytologically by Wright-Giemsa stain and/or Papanicolaou stain, at Tri-Service General Hospital. Immunocytochemical stainings were further performed to ensure the cell nature.

RESULTS

Eighteen of these patients had benign etiologies; the others suffered from malignant diseases. Sixteen cases, including eight benign and eight malignant, received pericardial biopsy for comparison. Commonly encountered cells in PE with any kind of etiology included neutrophils, lymphocytes macrophages and mesothelial cells. Cancer cells were additionally seen in malignant PE, but not in all cases with cancers. Furthermore, reactive mesothelial cells and macrophages were sometimes not easily distinguished from cancer cells, and reactive lymphocytes frequently mimicked hematopoietic malignancies. Further, the nature of small round tumor cells can hardly be ensured by morphologic examination only. Immunocytochemical studies were successfully used to solve these dilemmas in some suspicious cases.

CONCLUSIONS

This study showed that cytology together with clinical information and immunocytochemistry can achieve excellent sensitivity and specificity in identification of malignant PE. The use of immunocytochemistry can even ensure the nature of certain cancers such as small cell carcinoma and B cell lymphoma.

When do human macrophages release nitric oxide? Variable effects of certain in vitro cultural and in vivo resident conditions

Nitric oxide (NO) release from mouse and rat macrophages is implicated in tumor cell cytotoxicity and the killing of intracellular organisms. Evidence, however, suggests that human monocyte-derived macrophages or myeloid leukemic cells differentiated along the monocytic lineage do not consistently release NO. Results presented herein that human monocyte-derived macrophages in response to lipopolysaccharide can release NO, but markedly less than mouse macrophages (1.26 +/- 0.20 vs 42.5 +/- 6.3 microM). Different in vitro and in vivo conditions have variable effects on NO production by human macrophages. Monocytes cultured in plastic wells, but not teflon beakers, for 7 days can release NO (1.22 +/- 0.13 vs 0.14 +/- 0.07 microM). In addition, human resident macrophages derived from patients with certain diseases possess a calcium- and protein kinase C-dependent pathway to produce NO, in contrast to the calcium-independent and phosphatase-dependent NO release in murine macrophages. Above results suggest that the mechanism of producing NO by macrophages in humans is not only different from that in mice, but also depends on certain in vitro and in vivo conditions.

Expression of Epstein-Barr virus-encoded RNAs as a marker for metastatic undifferentiated nasopharyngeal carcinoma

BACKGROUND

Epstein-Barr virus (EBV) is associated with undifferentiated nasopharyngeal carcinoma (NPC). EBV-encoded nonpolyadenlyated RNAs (EBERs) are often used as a marker to detect EBV-infected NPC cells. This study was conducted to document the expression and determine the significance of EBERs in NPC cells at various metastatic sites.

METHODS

An in situ hybridization (ISH) technique was used to identify the presence of EBERs in paraffin embedded tissues of primary and metastatic sites obtained from 21 patients with NPC. Nineteen of these patients had undifferentiated lesions, and 2 had squamous cell carcinoma. One hundred and fifty specimens of normal tissues and tissues from patients with a variety of benign and malignant diseases other than NPC served as controls. In the NPC specimens, the expression of latent membrane protein (LMP) and a lytic protein, BZLF-1, were also examined by immunohistochemistry.

RESULTS

Tissues from all patients with undifferentiated NPC and one patient with squamous cell carcinoma contained EBERs in the malignant cells; the other case of squamous cell carcinoma was negative. In metastatic NPCs, LMP was expressed in 18% (4 of 22) of tissues whereas BZLF-1 was not expressed in any tissues. EBERs were not detected in the 43 patients with normal tissues and benign lesions. In malignant diseases other than NPC, EBERs were detected in only 2 of 12 cases of non-Hodgkin's lymphoma, 1 of 2 cases of Hodgkin's lymphoma, and 1 of 6 cases of gastric cancer.

CONCLUSIONS

By virtue of the direct correlation between latent EBV infection and NPC, the authors conclude that EBERs can be used as a sensitive marker to identify NPC cells at various metastatic sites by techniques of in situ hybridization, and that demonstration of EBERs in lesions of undifferentiated histology may be useful as a diagnostic adjunct for NPC presenting as metastatic cancer of unknown origin.

Allogeneic bone marrow transplantation for fourteen patients with severe aplastic anemia

BACKGROUND

Bone marrow transplantation (BMT) is the best curative approach for younger patients with severe aplastic anemia (SAA). Major obstacles to success of allogeneic BMT include graft-versus-host disease (GVHD), graft rejection and treatment related toxicities. Experience with 14 SAA patients who received BMT is reported here.

METHODS

From December 1986 to May 1995, 14 patients with SAA were treated with BMT; 13 were allogeneic, and 1 was syngeneic. There were nine males and five females whose average age was 24.7 years (range 15-36 years). The median pretransplant disease duration was 93 days (range 7-610 days). Five patients were nontransfused before BMT. The pretransplant conditioning regimen consisted of 200 mg/kg cyclophosphamide (CY) intravenously, divided over four consecutive days, followed by 300 cGy total-body irradiation (TBI) on the day before BMT. Two untransfused, one transfused patient and one syngeneic transplant received CY only as preconditioning. For GVHD prophylaxis, the 13 patients were given a combination of cyclosporine and a short course of methotrexate.

RESULTS

Of the 14 patients, 11 were still alive 10 to 90 months later, with functional engraftment; the median survival of 39 months. There were three deaths including one with primary graft failure with intracranial hemorrhage, and two with delayed graft rejection and sepsis. The patient who received syngeneic BMT developed late graft failure six months post-transplant, but was successfully treated with a second BMT. Acute GVHD occurred among 5 of the 13 engrafted patients, only one of whom was Grade III clinically. Chronic GVHD was observed in 2 out of 10 evaluable patients.

CONCLUSIONS

The combination of CY and TBI is an effective, well-tolerated conditioning regimen for BMT in patients with SAA. The acute GVHD rate was low in our patients receiving cyclosporine. BMT is the treatment-of-choice for patients under the age of 40 with SAA, for those with human leucocyte antigen (HLA)-identical siblings or an identical twin and particularly for those patients who have not received transfusion.

Bronchial foreign bodies in adults

Aspiration of foreign bodies into the bronchial tree is infrequently seen in adults. We reviewed 40 such cases during an 8-year period at Chang Gung Memorial Hospital, Kaohsiung. Only six patients had underlying conditions that contributed to the aspiration of foreign bodies. A positive history of aspiration was found in 18 patients (48%). Clinical manifestations were nonspecific. Chest roentgenograms were useful in 11 of the 40 patients. Bronchoscopic findings were classified into three groups: foreign bodies in the bronchial tree without granulation tissue, foreign bodies in the bronchial tree with marked granulation tissue and foreign bodies embedded in the granulation tissue. The diagnoses and removal of foreign bodies were successful in 37 patients (92%) using grasping forceps or biopsy forceps and in one patient using basket type grasping forceps. Complications of bronchoscopy were rare and not serious. The diagnosis of occult foreign bodies is often difficult and demands a high index of suspicion. Removal of endobronchial foreign bodies is usually possible with a flexible fiberoptic bronchoscope and has a high success rate.

Combination chemoimmunotherapy with interferon-alpha and cisplatin in patients with advanced non-small cell lung cancer

BACKGROUND

Non-small cell lung cancer (NSCLC) has a relatively low response rate to systemic chemotherapy. Recently, several investigations have shown that interferon may augment the cytotoxic effect of chemotherapeutic agents and may improve the result of chemotherapy in treating cancers.

METHODS

An open-label noncomparative phase II study investigated the efficacy and safety of combined chemoimmunotherapy for NSCLC using IFN-alpha, given by intramuscular injection with 9 million units thrice a week for a maximum of 26 weeks, and cisplatin by intravenous infusion, 100 mg/m2, every 4 weeks for a maximum of 6 cycles. Ten patients, with histology-confirmed NSCLC at stage IV of their diseases were enrolled. They included 5 men and 5 women, with an average age of 53.7 year. Five of them had adenocarcinoma; the other five had squamous cell carcinoma.

RESULTS

Five patients, including two patients with squamous cell carcinoma and three with adenocarcinoma, obtained a partial response (response rate 50%). The time needed to achieve a sustained response ranged from 5 to 13 weeks with a median of 8 weeks. The response duration ranged from 14 to 37 weeks with a median of 20 weeks. The overall survival time for the ten patients ranged from 2 to 20 months with a median of 8 months. All 10 patients needed dose modifications of IFN-alpha and/or cisplatin because of myelosuppression and/or impaired renal function. Other frequently encountered side effects included gastrointestinal disturbances and a flu-like syndrome, but these were well tolerated.

CONCLUSIONS

These preliminary results indicate that chemoimmunotherapy with IFN-alpha and cisplatin can be an effective alternative therapy for patients with advanced NSCLC, but there are significant side effects.

Diagnosis of primary cardiac lymphoma. Report of a case with cytologic examination of pericardial fluid and imprints of transvenously biopsied intracardiac tissue

BACKGROUND

Primary cardiac lymphoma (PCL) is a treatable disease when appropriately diagnosed. Therefore, a prompt, safe method with high diagnostic accuracy is prerequisite to successful therapy for PCL.

CASE

A 57-year-old male presented with exertional dyspnea and atrial fibrillations. A pericardial effusion (PE) and several tumor masses occupying both atria were found. Cytologic examinations of PE and of imprints of the tissues obtained by transvenous biopsy of the cardiac tumors revealed numerous small, round tumor cells and lymphoglandular bodies, suggestive of malignant lymphoma. This cytologic impression was confirmed by immunocytochemical studies on the same cytologic material. Histologic studies reaffirmed the diagnosis of B-cell lymphoma. The patient received eight courses of chemotherapy, with complete remission of the illness.

CONCLUSION

Cardiac lymphoma can be quickly and safely diagnosed by cytologic examination of PE or transvenously biopsied cardiac tissue, with confirmation by immunocytochemical studies. Exploratory thoracotomy for biopsy can be avoided.

Pyopneumothorax associated with unsuspected endobronchial foreign body: a case report

Chronic foreign body aspiration may cause a variety of complications. Nonspecific clinical presentations and chest radiographic manifestations often result in misdiagnosis or delayed diagnosis. We report an unusual complication of chronic foreign body aspiration--pyopneumothorax--in a 52-year-old patient presenting with productive cough and intermittent fever for more than 3 months. Obstructive pneumonia was highly suspected from the computed tomographic scan of the chest. Flexible fiberoptic bronchoscopy demonstrated a fish bone in the bronchial tree. The bone was successfully removed by forceps. Thoracotomy was done later to ensue adequate drainage of the pyopneumothorax. We report this case for ongoing education to increase the index of suspicion.

Generation of lymphokine-activated killer (LAK) cell activity from malignant peritoneal effusions

A generation of lymphokine-activated killer (LAK) cell activities from malignant peritoneal effusions was investigated in 10 patients with abdominal carcinomatosis. Five of the 10 patients were victims of colorectal cancers, three of gastric cancers, and one each of ovarian cancer and cholangiocarcinoma. Lymphocytes, the so-called effusion associated lymphocytes (EALs), were isolated from malignant peritoneal effusions by density gradient centrifugation and the plastic adherence method. These isolated EALs were subsequently cultured in the presence of recombinant interleukin-2(rIL-2), 3,000 I.U./ml, for 30 days. Natural killer (NK) cell activities and LAK cell activities of the freshly isolated and cultured EALs were examined at 0, 7, 14, and 30 days of culture by means of a standard 51Cr-release assay using K-562, HL-60, and autologous tumor cells as target cells. The NK cell activities of the freshly isolated EALs were not detected in any of the 10 patients. The LAK activities, however, could be generated in all of them, and the activities were maximal at 7 days. The longer the EALs remained in the culture, the weaker were the LAK cell activities. As far as cell growth was concerned, EALs proliferated well as long as the rIL-2 were present in the culture. Phenotypic analysis of the freshly isolated EALs revealed the presence of NK cells (22%, CD16+CD56+), T helper/inducer (18%, CD4+), T cytotoxic/suppressor (50%, CD8+), and B cells (8%, CD19+). After being cultured with rIL-2, the B lymphocytes gradually disappeared, and the T lymphocytes predominated with an increase in the percentage of T helper/inducer cells.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiotoxicity related to 5-fluorouracil chemotherapy: a report of two cases

5-Fluorouracil (5-FU) is a chemotherapeutic agent which has been used to treat many solid tumors including cancers of the breast, ovary, cervix, bladder, prostate gland and gastrointestinal tract. Side effects related to the drug include bone marrow suppression, stomatitis, nausea, vomiting and diarrhea. However another less frequent but lethal event cardiotoxicity--appears to have been ignored by physicians. Recently, two cases of cardiac toxicity induced by 5-FU have been encountered here. One patient developed supraventricular tachycardia and the other illustrated silent myocardial infarction with congestive heart failure. Since these side effects may result in death when 5-FU is prescribed to those patients who have had previous heart disease or are concomitantly receiving inevitable radiotherapy over the cardiac region, it should be recommended with extreme caution.

Diagnosis of disseminated candidiasis by fine needle aspiration of lymph node and by splenic imprint in a patient with acute promyelocytic leukemia

Cytologic studies were done on fine needle aspirates of the lymph node and imprints of splenic biopsies from a patient with acute promyelocytic leukemia who was febrile while being treated with chemotherapy. Examination of the lymph node aspirates revealed pus and numerous pseudohyphae which were later identified as Candida tropicalis. When multiple nodular lesions were detected in the spleen by abdominal sonography and CT scan, needle biopsy of the spleen was done. Cytologic examination of touch imprints of the biopsy disclosed intracellular fungal blastospores. The patient was treated with and responded well to amphotericin B and 5-fluorocytosine. As a result of our experience with this patient we emphasize the importance of close incorporation of clinical information and diagnostic cytology. With such a cooperation, cytologic studies become a most useful method for diagnosis.

Effects of indomethacin on lymphokine-activated killer cell activities in cancer patients

Prostaglandin E2 (PGE2) is known to downregulate the generation of lymphokine-activated killer (LAK) cell activity. Indomethacin, an inhibitor of cyclooxygenase catalyzing the biosynthesis of PGE2, has been shown to augment LAK cell activities generated from peripheral blood mononuclear cells of normal healthy individuals. This study was undertaken to examine whether or not this augmentation is also a common phenomenon in cancer patients. LAK cell activities generated in the presence and the absence of indomethacin were examined in 15 normal healthy individuals and in 83 cancer patients. Paired data analysis revealed that indomethacin exhibited a significant augmentation of LAK activity generated from healthy individuals. Indomethacin enhanced LAK activity in patients with no distant metastases (TxNxM0); but depressed LAK activity in patients with distant metastases (TxNxM1). In patients without distant metastases, indomethacin showed an upregulating effect on LAK activity in those with an early T stage (T1-2NxM0), and no such effect was detected in those with a late T stage (T3-4NxM0). Indomethacin also significantly enhanced LAK cell generation in cancer patients with an ECOG performance status of 1, but significantly inhibited LAK cell generation in patients with a performance status of 4. These results indicated that indomethacin inhibited generation of LAK cell activity in cancer patients with a poor performance status or with distant metastatic disease, who normally would be the subjects of adoptive immunotherapy. Further, PGE2 production in cultured LAK cell medium was suppressed by indomethacin in all 20 cancer patients that were examined, suggesting that other yet to be identified factors or mechanisms may be responsible for the paradoxical effects of indomethacin on LAK cell activity.

Acute pneumonitis after subcutaneous injections of silicone for augmentation mammaplasty

In a period of 3 years, seven cases of acute pneumonitis have been found after patients have been subcutaneously injected with silicone for the sole purpose of augmentation mammaplasty. Adverse symptoms following these silicone injections were fever, hypoxemia, hemoptysis, and abnormal diffuse bilateral alveolar infiltrates in both lungs. Pulmonary hemorrhaging occurred, and this was substantiated by using the bronchoscope with the bronchoalveolar lavage (BAL). The alveolar macrophage obtained from the BAL contained large quantities of pleomorphic cytoplasmic particles, which in actual fact were silicone particles. They were identified as silicone by scanning electron microscopy and energy-dispersive analysis of x-rays. This evidently showed that silicone diffusion into the circulatory system and subsequent embolization of the lung. Pulmonary function studies had shown restrictive changes with increase or normal single-breath carbon monoxide diffusing capacity (Dsb). Perfusion lung scans were interpreted as showing diffuse abnormalities consisting of decreased peripheral uptake. Acute hypoxemic respiratory failure was noted in four of these patients. Silicone injections of this nature were therefore a respiratory risk and caused the inducement of pneumonitis.

Diagnosis of fungemia in bone marrow transplantation patients by examination of peripheral blood smears

Two patients who received BMT for treatment of severe aplastic and AML-M2, developed fungemia during leukopenia. The organisms responsible for the infections were Candida parapsilosis and Rhodotorula glutinis, respectively. Early diagnosis of fungemia in these two patients was made by visualization of fungal blastospores in peripheral blood (PB) smears. These two cases illustrate that cytologic examination of PB smears is a useful method for early detection of fungus infection in BMT patients with leukopenia and unexplained fever in spite of appropriate antibiotic treatment.

The augmentation of lymphokine-activated killer cell activity by indomethacin in vitro is not mediated by prostaglandin E2 suppression

The effects of three nonsteroidal antiinflammatory drugs (NSAIDs), namely, indomethacin, aspirin, and mefenamate (ponstan), on the lymphokine-activated killer (LAK) cell activities generated from coculturing recombinant interleukin-2 (rIL-2) and normal human peripheral blood mononuclear cells (PBMCs) for 3 to 4 days were investigated. The LAK cell activities were measured by a 4 hour 51Cr release microcytotoxicity assay using HL-60 and K-562 as target cells. Indomethacin was found to have significant augmenting effect on LAK cell activity at the concentration of 5 x 10(-5) M, whereas aspirin and ponstan did not show the same effect at the same concentration. Additional experiments, however, demonstrated that all of these 3 agents could effectively suppress the production of prostaglandin E2 (PGE2) in the culture medium. These results indicated that PGE2 suppression may not be the only mechanism of indomethacin for upregulation of LAK cell activity, and even immune functions.

Treating carcinomatous pleural effusion by intrapleural injection of OK-432 in patients with non-small-cell lung cancer

The effect of intrapleural injection of OK-432, a streptococcal preparation, for management of carcinomatous pleural effusion was investigated in patients with non-small cell lung cancer (NSCLC). Ten patients, including 5 men and 5 women with performance status 2-3(ECOG) and average age of 66.4 years, received OK-432 for different times after the tumor burden in effusion was relieved with adequate drainage. The response rate was 100% in terms of decreased reaccumulation of pleural fluid, improvement of general status, and disappearance of tumor cells in the fluid. The adverse effects of this treatment were mild-including fever, chills, chest pain and nausea-and all were tolerable to patients. Median survival time was 4.5 months after treatment. This preliminary report indicates that intrapleural injection of OK-432 is an effective alternate method for management of carcinomatous pleural effusion to improve the quality of life for terminally ill cancer patients.

Primary cecal lymphoma. Report of a case with preoperative diagnosis by fine needle aspiration and immunocytochemistry

Fine needle aspiration of a cecal mass was performed on a patient with a cecal tumor and iron-deficiency anemia. Cytologic studies of the air-dried smears showed large cell lymphoma. The diagnosis of large cell lymphoma of the B-cell type was affirmed by immunocytochemical studies and at laparotomy and resection of the tumor. Even under unusual circumstances, the diagnosis of such a rare abdominal lesion as primary cecal lymphoma can be made with certainty by cytologic and immunologic studies of fine needle aspirates.