Viral eradication reduces both liver stiffness and steatosis in patients with chronic hepatitis C virus infection who received direct-acting anti-viral therapy

BACKGROUND

Whether direct-acting anti-viral therapy can reduce liver fibrosis and steatosis in patients with chronic hepatitis C virus (HCV) infection is unclear.

AIMS

To evaluate changes in liver stiffness and steatosis in patients with HCV who received direct-acting anti-viral therapy and achieved sustained virological response (SVR).

METHODS

A total of 198 patients infected with HCV genotype 1 or 2 who achieved SVR after direct-acting anti-viral therapy were analysed. Liver stiffness as evaluated by magnetic resonance elastography, steatosis as evaluated by magnetic resonance imaging-determined proton density fat fraction (PDFF), insulin resistance, and laboratory data were assessed before treatment (baseline) and at 24 weeks after the end of treatment (SVR24).

RESULTS

Alanine aminotransferase and homeostatic model assessment-insulin resistance levels decreased significantly from baseline to SVR24. Conversely, platelet count, which is inversely associated with liver fibrosis, increased significantly from baseline to SVR24. In patients with high triglyceride levels (≥150 mg/dL), triglyceride levels significantly decreased from baseline to SVR24 (P = 0.004). The median (interquartile range) liver stiffness values at baseline and SVR24 were 3.10 (2.70-4.18) kPa and 2.80 (2.40-3.77) kPa respectively (P < 0.001). The PDFF values at baseline and SVR 24 were 2.4 (1.7-3.4)% and 1.9 (1.3-2.8)% respectively (P < 0.001). In addition, 68% (19/28) of patients with fatty liver at baseline (PDFF ≥5.2%; n = 28) no longer had fatty liver (PDFF <5.2%) at SVR24.

CONCLUSION

Viral eradication reduces both liver stiffness and steatosis in patients with chronic HCV who received direct-acting anti-viral therapy (UMIN000017020).

Ability of 18-fludeoxyglucose positron emission tomography/CT to detect incidental cancer

OBJECTIVE

To determine the prevalence and clinical features of pathologically proven incidental cancer (IC) detected by whole-body fluorine-18 fludeoxyglucose ((18)F-FDG) positron emission tomography (PET)/CT, as well as the incidence of false-positive and false-negative results.

METHODS

We retrospectively reviewed reports derived from (18)F-FDG PET/CT images of 3079 consecutive patients with known or suspected malignancies for 3 years. Discrete focal uptake indicating IC was identified from reports as well as pathological or clinical diagnoses, and the clinical courses were investigated. The false-positive result was defined as uptake indicating IC but not pathologically confirmed as malignant during follow-up. The false-negative result was defined as pathologically proven IC detected by another modality at initial clinical work-up or diagnosed during the follow-up period.

RESULTS

We found (18)F-FDG uptake indicating IC in 6.7% of all patients, and IC was pathologically proven in 2.2% of all patients. The most common sites were the colon, lung and stomach. The median survival duration of patients with IC was 42 months. The results were false positive in 4.5% of all patients, and the results were false negative in 2.3% of all patients.

CONCLUSION

(18)F-FDG PET/CT is a valuable tool for detecting IC. The rates of false-positive and false-negative results are within acceptable range.

ADVANCES IN KNOWLEDGE

This is the first report to describe the survival of patients with IC, and the detailed features of false-negative results at actual clinical settings.

Correlation of serum ribavirin concentration with pretreatment renal function estimates in patients with chronic hepatitis C receiving combination antiviral therapy with peginterferon and ribavirin

Serum ribavirin concentration is an important factor in antiviral therapy in combination with peginterferon (PEG-IFN) and ribavirin for patients with chronic hepatitis C in terms of both beneficial and adverse effects. We evaluated whether the serum ribavirin concentration can be predicted on the basis of renal function estimates. Serum creatinine and cystatin C concentrations were measured at the start of treatment in a total of 148 patients with chronic hepatitis C who underwent combination PEG-IFN and ribavirin therapy. Creatinine clearance (CrCl) and total clearance of ribavirin (CL/F) were calculated on the basis of the serum creatinine level. The glomerular filtration rate was calculated with two different formulae on the basis of the serum cystatin C level. These values were compared with serum ribavirin concentrations 4 weeks after the start of therapy. The cystatin C level increased with the progression of liver fibrosis, whereas the creatinine level was constant regardless of the degree of liver fibrosis. Significant correlation was not observed between the serum ribavirin concentration and serum creatinine level, cystatin C level, or calculated renal function estimates. However, significant correlation was found between the serum ribavirin concentration and CrCl and CL/F in patients who were given ribavirin >800 mg/day. Overall, renal function estimates do not correlate with the serum ribavirin concentration in Japanese patients with chronic hepatitis C who undergo combination PEG-IFN and ribavirin therapy. Serum creatinine-based renal function estimates might be predictive for the serum ribavirin concentration only in patients with a daily ribavirin intake of 800 mg or more.

Endoscopic management and follow up of Dieulafoy lesion in the upper gastrointestinal tract

BACKGROUND AND STUDY AIMS

Dieulafoy's lesion is an important cause of upper gastrointestinal bleeding, and the safety and efficacy of endoscopic treatment have been widely accepted. The aim of this study was to evaluate the effectiveness of endoscopic management, including hemoclipping and injection methods, for bleeding Dieulafoy lesions in the upper gastrointestinal tract.

PATIENTS AND METHODS

Between 1995 and 2003, 61 patients with bleeding Dieulafoy lesions underwent endoscopic treatment. The available hemostatic methods were hemoclipping, hypertonic saline-epinephrine injection, and pure ethanol injection. Clinical data, endoscopic features, and treatment outcome were analyzed retrospectively.

RESULTS

Comorbid conditions were present in 39 patients (64 %). Active bleeding was noted in 20 patients (33 %). Hemoclipping was a selected treatment in 48 patients (79 %). Initial hemostasis was achieved in 61 patients (100 %). One patient had rebleeding 6 days after the initial procedure but was successfully treated endoscopically. The 30-day mortality was 0 %. During follow-up, for a mean of 47 months, 15 patients (25 %) died of causes unrelated to the Dieulafoy lesion. Two patients had recurrent bleeding due to non-Dieulafoy gastric ulcer, and responded to endoscopic therapy. We encountered no patients who required surgery.

CONCLUSIONS

Dieulafoy lesion can be successfully managed by endoscopic treatment. The long-term outcome is acceptable.

Energy expenditure during walking with weight-bearing control (WBC) orthosis in thoracic level of paraplegic patients

STUDY DESIGN

Comparative study of the effectiveness of walking exercise with a newly developed gait orthosis, the weight-bearing control (WBC) orthosis, for thoracic level of paraplegic patients.

OBJECTIVES

To test its feasibility as a rehabilitation alternative for paraplegic patients, the energy consumption and cost during walking with WBC were calculated and compared with the values of conventional orthoses given in previous reports.

SETTING

National Rehabilitation Center for the Disabled, Japan.

METHODS

Four paraplegic patients with traumatic spinal cord injuries ranging from T8 to T12 participated. Experiments were conducted after 3 months of the orthotic gait training with WBC. The cardiorespiratory parameters were continuously measured at rest and during walking with a telemetric device. The steady-state value of the oxygen uptake (V(O2)), heart rate (HR), the energy consumption (J/kg/s) and energy cost (J/kg/m) were calculated.

RESULTS

The average walking speed was 19.0 +/- 2.58 m/min. The steady-state value of the V(O2) and HR were 16.08 +/- 1.93 ml/kg and 147.3 +/- 10.94 b/min, respectively. The energy cost during orthotic walking tended to be better than the values of conventional orthoses, whereas the energy consumption was almost similar.

CONCLUSION

WBC enables thoracic level of paraplegic patients to walk at relatively higher speed than conventional orthoses under similar energy expenditure. The special devices equipped with WBC are therefore considered to lead to improvement of the energy cost of walking. The physical intensity presumed by cardiorespiratory responses during walking with WBC is suited to promote their aerobic capacity. Therefore, it is concluded that the WBC orthosis could be an effective alternative in rehabilitation for thoracic level of paraplegic patients.

Liver dysfunction among workers handling 5-nitro-o-toluidine

BACKGROUND

5-Nitro-o-toluidine is an aromatic nitro amino compound. While other aromatic compounds are known to damage the human liver and are registered as toxic substances, toxicity information concerning 5-nitro-o-toluidine is lacking.

AIMS

To investigate the hepatotoxicity of 5-nitro-o-toluidine.

PATIENTS AND METHODS

Of 15 workers in the same factory who handled 5-nitro-o-toluidine, three were hospitalised with symptoms of acute liver dysfunction. Suspecting a link between liver dysfunction and working conditions, we correlated workplace factors with clinical findings in all 15 workers.

RESULTS

Blood biochemistry tests indicated liver damage in seven of 15 study subjects. Workers who handled 5-nitro-o-toluidine and nitrosyl sulphuric acid often loosened their respiratory protective equipment shortly after 5-nitro-o-toluidine powder had been dispersed into the air of the room. No potential hepatotoxins were present except for 5-nitro-o-toluidine. Six of the affected workers had handled 5-nitro-o-toluidine 12 to 20 times; the seventh worker had handled the powder three times; and the other eight workers without liver dysfunction had handled the material once or twice. No other significant differences in background were evident between the affected and unaffected workers, such as age, sex, or protective measures. Histological findings during recovery from liver damage were similar to those of acute viral hepatitis. None of the 15 subjects has demonstrated liver damage since the factory was closed.

CONCLUSIONS

A link between liver dysfunction and 5-nitro-o-toluidine exposure is suggested by greater severity of liver dysfunction associated with more episodes of handling.

Effect of the dose and duration of interferon-alpha therapy on the incidence of hepatocellular carcinoma in noncirrhotic patients with a nonsustained response to interferon for chronic hepatitis C

OBJECTIVE

We evaluated the effect of dose and duration of treatment with interferon (IFN)-alpha on the incidence of hepatocellular carcinoma (HCC) after IFN treatment in patients with chronic hepatitis C.

METHODS

A total of 291 noncirrhotic patients with chronic hepatitis C without hepatitis B virus coinfection in whom hepatitis C virus (HCV) was not eradicated by IFN-alpha therapy were retrospectively analyzed. The incidence of HCC after IFN therapy was compared according to the total dose or duration of treatment.

RESULTS

Patients were followed up for 6-117 months after the end of IFN treatment. The duration of IFN treatment (< or =24 vs. >24 weeks) had no effect on the incidence of HCC. However, the incidence of HCC was significantly lower in patients who received >500 million units of IFN as a total dose than in patients who received < or =500 million units of IFN (p = 0.0480), and the total dose of IFN (>500 million units) was an independent factor affecting the incidence of HCC (p = 0.0405). In addition, when focusing on patients whose histology was F2 or F3 before IFN treatment, the suppressive effect of the total dose of IFN (>500 million units) was emphasized (p = 0.0049 in generalized Wilcoxon test and p = 0.0178 in multivariate analysis).

CONCLUSIONS

Patients with chronic hepatitis C should receive more than 500 million units of IFN when IFN is used to decrease the incidence of subsequent HCC.

[A new development in interventional radiology for hepatocellular carcinoma]

In Japan, interventional radiology (IVR) treatments such as transcatheter arterial embolization (TAE), percutaneous ethanol injection therapy (PEIT), and intraarterial infusion chemotherapy play an important role in the treatment of hepatocellular carcinoma because of the associated cirrhosis (impairment of liver function) and occasional multicentricity. With progress in catheters, embolic materials, and imaging equipment such as the so-called "IVR-CT", superselective TAE and precise evaluation of tumor lesions has become feasible. However, the impact of TAE on survival in patients with hepatocellular carcinoma remains to be determined because no survival benefit was seen in four of five randomized controlled trials (RCTs) in Europe and Eastern countries, in which TAE was compared with no treatment (3 trials), i.v. 5-fluorouracil (1 trial), or tamoxifen (1 trial). To resolve questions arising from these results, a fair number of trials, particularly RCTs are needed in Japan.

Effect of skin pressure by clothing on small bowel transit time

We examined the effect of increased skin pressure from tight clothing on small bowel transit time by means of the breath hydrogen test, using milk that contained lactulose as an additional indigestible disaccharide, which is used as a test meal after overnight fasting. In this experiment, we measured the small bowel transit time from 9 healthy and non-constipated female subjects with two different skin pressures that were applied by loose-fitting experimental garment or an additional tight-fitting girdle on two consecutive days. The skin pressure of the latter condition was 8-9 mmHg higher than that of the former one on the participants' waist, abdomen and hip region. The experimental order of the two skin pressure conditions was counterbalanced. As a result, the small bowel transit time obtained with and without girdle did not differ significantly (165.0 +/- 26.0 minutes for less skin pressure condition and 173.3 +/- 26.8 minutes for more skin pressure condition, n = 9, p = 0.43). This result indicated that the skin pressure from clothing has no effect on the passage rate of food through the small intestine.

Bullectomy is beneficial in the pulmonary blood flow/driving pressure relationship in bullous emphysema patients

OBJECTIVES

Few physiological studies have been on pulmonary circulation, including the relationship between pulmonary blood flow and driving pressure, and viscosity changes arising from hematocrit changes before versus after lung volume reduction Surgery or bullectomy in emphysematous patients.

METHODS

We studied the relationship between pulmonary blood flow and driving pressure before and after bullectomy using a unilateral pulmonary artery occlusion test based on pulmonary blood flow fractions obtained by pulmonary blood flow scintigraphy in 7 patients with pulmonary emphysema associated with bullae.

RESULTS

Among the 7 undergoing bullectomy, the pulmonary blood flow/driving pressure relationship decreased in 5 and was unchanged in 2. Of the 11 lungs treated by bullectomy, this relationship decreased in 8 lungs, but not 3 (p < 0.01). No significant difference was seen in oxygen partial pressure in arterial and mixed venous blood or hematocrit.

CONCLUSION

We concluded that bullectomy shifted the pulmonary blood flow/driving pressure relationship downword in some cases with significant bullae.

Impact of diabetes mellitus on the prognosis of patients with hepatocellular carcinoma

BACKGROUND

The majority of patients with hepatocellular carcinoma (HCC) have coexisting cirrhosis or chronic hepatitis, often complicated by diabetes mellitus. In the current study, the authors evaluated the impact of diabetes mellitus on the prognosis of patients with HCC.

METHODS

Among 581 patients with HCC who had been diagnosed and treated between 1990 and 1999, survival was compared between those patients with and those patients without diabetes mellitus. The rate of disease recurrence after treatment also was analyzed.

RESULTS

Ninety-two patients (15.8%) had diabetes mellitus. There was no significant difference with regard to patient characteristics (i.e., age, gender, or alcohol intake) or liver function between those patients with and those patients without diabetes mellitus. No differences were observed in survival between patients with diabetes mellitus and patients without it. Among the 195 patients with a solitary HCC lesion measuring < or = 3 cm in greatest dimension, the survival of the 32 patients with diabetes mellitus was significantly poorer than that of the 163 patients without diabetes mellitus (P = 0.0273), despite no apparent difference in liver function between the 2 groups. On multivariate analysis, diabetes mellitus was found to be an independent factor predicting lower survival after treatment (P = 0.0077) among patients with a solitary HCC lesion measuring < or = 3 cm in greatest dimension. No difference in the rate of recurrence was observed between the two groups in all the patients and in those patients with a solitary HCC lesion measuring < or = 3 cm in greatest dimension.

CONCLUSION

The results of the current study indicated that the presence of diabetes mellitus worsens the prognosis of patients with a solitary HCC lesion measuring < or = 3 cm in greatest dimension; it appears to impact prognosis in patients with HCC when HCC is treatable, based on the size and the number of lesions. However, diabetes mellitus did not appear to affect the prognosis in the general population of patients with HCC. Based on the current study data, diabetes mellitus does not appear to modify the progression of HCC and its recurrence after treatment, but it does appear to worsen the prognosis of patients with HCC by means of a rapid decline in remnant liver function caused by repeated treatment of HCC.

Characteristics and course of small hepatocellular carcinomas in patients with hepatitis C virus types 1 and 2

The associations between types of HCV and tumor characteristics and recurrence and survival after treatment of small HCC were investigated. Viral genotype-specific antibodies were measured in sera obtained at the time of diagnosis of HCC, in 92 patients with HCC < or = 2 cm in diameter who were treated between 1990 and 1998. The degrees of tumor differentiation and angiographically-evaluated hypervascularity were compared between patients infected with HCV type 1 and those with type 2. Survival, time to recurrence, and patterns of recurrence after initial treatment also were compared. On pathologic evaluation, 6 of 21 HCC (28.6%) in patients with HCV type 2 were well-differentiated, whereas 28 of 48 HCC (58.3%) in patients with HCV type 1 were well-differentiated (P = 0.0229). HCC in patients with HCV type 2 showed hypervascularity more frequently than HCC in patients with HCV type 1, with tumor staining evident by digital subtraction arteriography in 17 of 22 patients with HCV type 2 (77.3%) vs. 20 of 50 in patients with HCV type 1 (40.0%, P = 0.0036). Survival and overall recurrence rates were similar in patients infected with HCV type 1 and with HCV type 2 (P = 0.5537). In the analyses of patterns of recurrence, recurrences in patients infected with HCV type 2 were relatively more likely to be intrahepatic metastases (P = 0.0342), that was closely related to the differentiation of HCC. Multicentric occurrence of HCC was a more frequent type of recurrence in patients with HCV type 1 (P = 0.1619), and infection of HCV type 1 was an independent factor for multicentric occurrence in multivariate analysis (P = 0.0021). In HCC < or = 2 cm in diameter, HCV type 2 is associated with more progression of HCC than HCV type 1, whereas patients with HCV type 1 may be at higher risk for multicentric HCC occurrence after the treatment of HCC.

Everyday breath hydrogen excretion profile in Japanese young female students

A breath hydrogen test has been used widely as a noninvasive and simple method of detecting carbohydrate malabsorption as well as estimation of the small intestinal and orocecal transit time. By means of this method, we have examined the change in breath hydrogen concentration of young female students in their everyday life in order to reveal the breath hydrogen excretion profile under normal circumstances. In this survey, we have asked them to collect their own breath samples every one-hour as regularly as possible during one day from awakening until bedtime. We also asked them to complete the questionnaire concerning their dietary habit, dietary record and physical activities. Among the 43 subjects who gave the breath hydrogen records, 37 subjects excreted detectable hydrogen into their alveolar air. By comparing the changes in breath hydrogen concentration during the time of day, breath hydrogen excretions could be classified into two distinct patterns; more than half of the total hydrogen excretion occurred in the first half of the waking hours (designated as "pattern A", 18 cases) and in the latter half (designated as "pattern B", 19 cases). Taking into consideration the subjects' records of diets and physical activities, the early-pronounced breath hydrogen excretion observed among 18 "pattern A" students was probably resulted from the malabsorption of the dietary carbohydrate in the breakfast meals.

[A case of aneurysm of the ductus arteriosus in the adult]

Aneurysm of the ductus arteriosus in the adults is rare. A 60-year-old male with no symptoms was admitted to our hospital. 3 D-CT scans and aortograms indicated a diagnosis of aneurysm of the ductus arteriosus. Operation was done through median sternotomy with the aid of partial cardiopulmonary bypass. The saccular aneurysm was located between the aortic isthmus and the left pulmonary artery. The aneurysm was resected and closed a patch. The post-operative course was uneventful.

Effects of skin pressure by clothing on digestion and orocecal transit time of food

In order to reveal the influence of clothing skin pressure on digestion of food through the gastrointestinal tract, we examined the absorption of dietary carbohydrate and orocecal transit time of a test meal by means of a breath hydrogen test on 7 healthy young women. In this experiment, we collected breath samples from the participants wearing loose-fitting experimental garment on the second day of the experiment and from the same participants but wearing an additional tight-fitting girdle on the following day for 16 hours and 9 hours, respectively. Skin pressure applied by a girdle on participant's waist, abdomen and hip region was 15.5 +/- 0.4 mmHg (mean +/- SE), 11.0 +/- 0.2 mmHg, and 13.6 +/- 0.6 mmHg, respectively, and the values were 2-3 times larger than those of the experimental garment. The hydrogen concentration vs. time curve showed that breath hydrogen levels at its peaks (15:00, 15:30, 16:00, 16:30, and 17:00 hr) on the third day of the experiment were significantly higher than those of the corresponding time on the second day (p < 0.05 at 17:00 and 15:00, p < 0.01 at 15:00, 16:00 and 16:30). Consequently, significantly pronounced breath hydrogen excretion was observed under the "pressure" clothing condition (p < 0.01). On the other hand, the transit time of the test meal for the subjects wearing a girdle did not differ significantly from that for the subjects wearing the garment of less pressure (270 +/- 18 minutes and 263 +/- 21 minutes, respectively). These results indicate that the clothing skin pressure has an inhibitory effect on the absorption of dietary carbohydrate in the small intestine, but no effect on the orocecal transit time of a meal.

Characterization of cross-links between cellulose microfibrils, and their occurrence during elongation growth in pea epicotyl

The occurrence and chemical nature of the cross-links between cellulose microfibrils in outer epidermal cell walls in Pisum sativum cv. Alaska was investigated by rapid-freezing and deep-etching techniques coupled with chemical and enzymatic treatments. The cell wall in the elongating region of epidermal cells was characterized by the absence of the cross-links, while in the elongated region, the cell wall was characterized by the presence of cross-links. The cross-links remained in the cell wall of the elongated region after treatment with SDS electrophoresis sample buffer and treatment with 4% potassium hydroxide. After treatment with endo-1,4-beta-glucanase, which fragments xyloglucan, the cross-links were remarkably reduced from the cell wall of the elongated region. The endoglucanase treatment also reduced immunogold labeling of xyloglucan in the cell wall. The endoglucanase hydrolysate from the cell wall fraction of the elongated region gave spots of oligosaccharides in thin layer chromatography, which were identical to the spots of xyloglucan oligosaccharides produced by xyloglucanase from both the cell wall fraction and tamarind xyloglucan. These results indicate that the cross-links are made of xyloglucan. We discussed the possibility of cross-links involved in the control of mechanical properties of the cell wall.

The effect of retreatment with interferon-alpha on the incidence of hepatocellular carcinoma in patients with chronic hepatitis C

BACKGROUND

Interferon (IFN) has been reported to have beneficial long term effects that reduce the occurrence of hepatocellular carcinoma (HCC), even in patients who do not have complete responses to IFN. The authors evaluated the effect of retreatment with IFN-alpha on the long term prognoses of those with incomplete responses to their initial IFN-alpha treatment.

METHODS

Among 271 patients with incomplete responses to initial IFN-alpha treatment who had received sufficient dose and duration (a total dose of more than 350 megaunits administered over a period longer than 12 weeks) between October 1989 and September 1997, 63 patients received retreatment and 208 did not. The authors retrospectively compared the incidence of HCC between patients who received retreatment and those who did not.

RESULTS

There were no significant differences in the clinical characteristics between these two groups. The cumulative incidence of HCC was significantly lower among the patients who had retreatment, and retreatment with IFN-alpha was the only factor that correlated with the lower incidence of HCC in multivariate analysis. The results were similar when the 12 patients with complete responses to retreatment were excluded from the analysis.

CONCLUSIONS

Retreatment with IFN-alpha appeared to have the additional effect of suppressing the development of HCC in patients who had incomplete responses to the initial treatment, even when the hepatitis C virus was not cleared (i.e., a complete response was not achieved) with retreatment. Further prospective study is required.

The effect of retreatment with interferon-alpha on the incidence of hepatocellular carcinoma in patients with chronic hepatitis C

BACKGROUND

Interferon (IFN) has been reported to have beneficial long term effects that reduce the occurrence of hepatocellular carcinoma (HCC), even in patients who do not have complete responses to IFN. The authors evaluated the effect of retreatment with IFN-alpha on the long term prognoses of those with incomplete responses to their initial IFN-alpha treatment.

METHODS

Among 271 patients with incomplete responses to initial IFN-alpha treatment who had received sufficient dose and duration (a total dose of more than 350 megaunits administered over a period longer than 12 weeks) between October 1989 and September 1997, 63 patients received retreatment and 208 did not. The authors retrospectively compared the incidence of HCC between patients who received retreatment and those who did not.

RESULTS

There were no significant differences in the clinical characteristics between these two groups. The cumulative incidence of HCC was significantly lower among the patients who had retreatment, and retreatment with IFN-alpha was the only factor that correlated with the lower incidence of HCC in multivariate analysis. The results were similar when the 12 patients with complete responses to retreatment were excluded from the analysis.

CONCLUSIONS

Retreatment with IFN-alpha appeared to have the additional effect of suppressing the development of HCC in patients who had incomplete responses to the initial treatment, even when the hepatitis C virus was not cleared (i.e., a complete response was not achieved) with retreatment. Further prospective study is required.

Combined thoracic aortic or upper digestive tract resection for lung cancer and malignant mediastinal tumor

OBJECTIVE

We studied possible indications and combined resection in patients with lung cancer and mediastinal tumors requiring combined thoracic aortic or upper digestive tract resection.

METHODS

Ten patients with lung cancer and malignant mediastinal tumors (9 men and 1 woman aged 39 to 72 years; mean: 60.5) underwent combined aortic or upper digestive tract resection.

RESULTS

Five--3 [corrected] with primary lung cancer, 1 with thymic cancer, and 1 with liposarcoma--, underwent combined aortic resection. In 2 each, lung cancer and malignant mediastinal tumor had infiltrated the thoracic aorta. The remaining case of lung cancer was complicated by aortic aneurysm in the distal arch. Cardiopulmonary bypass was conducted in 4, and selective cerebral perfusion in 2. Three patients are alive after 11, 22, and 61 months without disease recurrence. Those undergoing combined upper digestive tract resection all had lung cancer, with 4 having tumors infiltrating the esophagus or corpus ventriculi. The remaining patient had both lung and esophageal cancer. The patient treated with combined corpus ventriculi resection has survived 24 months and the patient treated with combined esophageal resection has survived 12 months without disease recurrence. The 1-year survival rate was 60%, 2-year 23%, and 3-year 23%. Prognosis was generally poor with the longest survival 13 months with N2 lung cancer.

CONCLUSIONS

In combined resection due to malignant mediastinal tumor, T4N0-1 lung cancer, or diseases such as aortic aneurysm, prognosis can be expected to improve. Despite the often poor prognosis in T4N2 lung cancer, surgical intervention may be indicated to avoid complications due to tumor invasion and to lengthen survival and improve quality of life.

Risk factors for lung cancer among Northern Thai women: epidemiological, nutritional, serological, and bacteriological surveys of residents in high- and low-incidence areas

Lung cancer incidence among Northern Thai women is one of the highest in Asia (an annual age-adjusted incidence rate of 37.4 per 100,000), and the incidence rate significantly differs by geographical districts. Therefore, we conducted a comparative study of women living in the Sarapee area, which showed the highest (crude incidence rate, 40.9), and the Chom Tong area, which had one of the lowest incidence rates (8.5) in Chiang Mai Province, despite the two areas' geographical and cultural closeness. The women in this study were either family members of lung cancer patients or their neighbors. To find clues to the etiology of lung cancer, this study used various epidemiological and biochemical approaches: interviewing on lifestyle factors, duplicate meals, chemical examination of drinking water, biochemical analysis of sera, mutagenicity test of urine, and monitoring of fungi and bacteria in the living environment. We found that tobacco smoking (Khiyo, local cigars) was less frequently observed in Sarapee (high incidence), compared with Chom Tong (low incidence), and that the history of chronic benign respiratory diseases was the most distinct event among women in Sarapee, resulting in a significantly increased percentage of those with a history of both benign respiratory diseases and tobacco smoking. This population revealed increased levels of serum tumor necrosis factor (TNF)-alpha, an endogenous tumor promoter. Furthermore, significantly increased urine mutagenicity was found to be closely associated with history of benign respiratory disease in Sarapee. The fungus which was most commonly found in the air inside houses in Sarapee was identified as Microsporum canis. Additionally, significantly increased serum concentrations of a constituent of the fungus were found in Sarapee women, compared with those in Chom Tong. Our results suggest that tobacco (Khiyo) smoking alone may not be able to explain the very high incidence of female lung cancer in Northern Thailand, and that chronic benign respiratory disease, possibly caused by the infection of fungi such as M. canis, is likely to be involved in the etiology of female lung cancer in North Thailand.

Intravascular macrophage depletion attenuates endotoxin lung injury in anesthetized sheep

We recently showed that we can selectively and safely deplete most (average 85%) of the pulmonary intravascular macrophages in sheep by intravenously infusing liposomes containing dichloromethylene bisphosphonate. After a 1-h stable baseline, we made a 6-h comparison after a 30-min intravenous endotoxin infusion (1 microg/kg) between six anesthetized control lambs and six anesthetized lambs in which the intravascular macrophages had been depleted 24 h previously. Three of the control lambs had been macrophage depleted and allowed to recover their intravascular macrophage population for >/=2 wk. After depletion, both the early and late pulmonary arterial pressure rises were dramatically attenuated. Our main interest, however, was in the acute lung microvascular injury response. The early and late rises in lung lymph flow and the increase in lung lymph protein clearance (lymph flow x lymph-to-plasma protein concentration ratio) were >90% attenuated. We conclude the pulmonary intravascular macrophages are responsible for most of the endotoxin-induced pulmonary hypertension and increased lung microvascular leakiness in sheep, although the unavoidable injury of other intravascular macrophages by the depletion regime may also contribute something.

Usefulness of measurement of Lens culinaris agglutinin-reactive fraction of alpha-fetoprotein as a marker of prognosis and recurrence of small hepatocellular carcinoma

OBJECTIVE

Lens culinaris agglutinin-reactive fraction of alpha-fetoprotein (AFP-L3%) is a recently described marker of hepatocellular carcinoma (HCC), and its usefulness has been demonstrated in many studies. We evaluated the usefulness of serial measurement of AFP-L3% as a marker of prognosis and recurrence after treatment of small HCC.

METHODS

AFP-L3% was measured before and after initial treatment in 60 patients with small HCC (maximum diameter < or = 2 cm). AFP-L3% was taken as the ratio of AFP-L3 to total AFP and multiplied by 100%, and levels > or = 10% were considered positive. Outcomes and recurrence were compared between patients AFP-L3%-negative after initial treatment (Group A, n = 43) and patients who were AFP-L3%-positive after initial treatment (Group B, n = 17).

RESULTS

Before treatment, AFP-L3% was positive in 14 (23.3%) of the 60 patients. The cumulative survival rate of Group A was significantly longer (p = 0.0091) than that of Group B. The recurrence rate was significantly higher in Group B (p = 0.0104) than in Group A. When recurrence was limited to intrahepatic metastasis, the recurrence rate was significantly higher in Group B (p = 0.0064). However, the recurrence rate of multicentric occurrence did not differ significantly between Groups A and B.

CONCLUSIONS

Measurement of AFP-L3% after treatment may be useful for understanding prognosis and recurrence of HCC.

[Clinical effectiveness of degradable starch microspheres (DSM) in patients with liver cancer]

Recently, degradable starch microspheres (DSM) have become available for use in patients with liver cancer in Japan. When DSM combined with a cytotoxic drug are infused through the hepatic artery, the steep drug concentration gradient to the tumor tissue results in a higher tissue drug concentration, which may elicit an increased antitumor response by blocking regional blood flow. Furthermore, the reduced systemic exposure of a coinjected drug can be translated into an increased regional extraction ratio due to blood flow reduction. DSM is infused via a catheter connecting to a subcutaneously implanted reservoir in outpatients. Pain is experienced by all patients. Other frequently observed adverse reactions are nausea and vomiting. However, these symptoms improve within a few hours. These observations indicate that intra-arterial chemotherapy combined with DSM may provide a more potent anticancer effect than a cytotoxic drug alone.

Clinical utility of Lens culinaris agglutinin-reactive alpha-fetoprotein in small hepatocellular carcinoma: special reference to imaging diagnosis

BACKGROUND/AIMS

Blood concentration levels of alpha-fetoprotein like the Lens culinaris agglutinin-reactive fraction (AFP-L3) are a useful marker for predicting the long-term prognosis of hepatocellular carcinoma. This study investigated the relationship between serum AFP-L3 and various imaging modalities.

METHODS

Sixty-three patients with small hepatocellular carcinomas < or = 2 cm in diameter were studied. Serum AFP-L3 concentrations were measured by lectin-affinity electrophoresis coupled with antibody-affinity blotting and expressed as % AFP-L3 (the percent of AFP-L3 as total AFP). A clinical "cutoff level" of 10% was used in this study to indicate the presence of hepatocellular carcinoma. Selective hepatic intraarterial digital subtraction angiography (DSA), ultrasonographic angiography with carbon dioxide microbubbles (USAG), and computed tomography during arterial portography (CTAP) were performed to evaluate the hemodynamics of hepatic nodules.

RESULTS

Fourteen (22.2%) of the 63 patients were positive for % AFP-L3. The % AFP-L3 levels (n=45, 4.4%) of patients with hypervascular tumors were significantly higher than those (n=15, 0.0%) of patients with isovascular or hypovascular tumors as determined by USAG (p=0.0061). The % AFP-L3 levels (n=53, 4.4%) of patients with a negative portal blood supply were significantly higher than the % AFP-L3 levels (n=7, 0.0%) of patients with a positive portal blood supply as determined by CTAP (p=0.0140). The % AFP-L3 levels of patients with tumors with a long doubling time (DT) were significantly lower than for patients with tumors with a short DT (p=0.0176).

CONCLUSION

AFP-L3 is a positive indicator which may be more specific for small advanced hepatocellular carcinoma.

Detection of hepatic tumors: arterial-phase MR imaging versus spiral CT arteriography

BACKGROUND

To compare the utility of arterial-phase magnetic resonance (APMR) imaging and spiral computed tomography arteriography (CTA) for detection of hepatic tumors.

METHODS

Both APMR imaging and CTA were performed in 24 patients with liver tumors. APMR imaging was initiated at 25-30 s after an intravenous bolus injection of gadolinium-diethylenetriamine pentaacetic acid using the fast multiplanar spoiled GRASS technique. CTA was initiated at 3 s after hepatic arterial injection of 30-64% nonionic contrast agent. APMR and CTA images were separately reviewed retrospectively by two blinded readers. Afterward, matched pair was reviewed to determine which had better lesion conspicuity.

RESULTS

The sensitivities for hepatic tumors were 67.2 and 86.6% in APMR and CTA, respectively (p < 0.01). Seven (12.5%) and 21 (23.9%) false-positive lesions were seen at APMR and CTA, respectively (NS). Lesion conspicuity was comparable between APMR and CTA.

CONCLUSIONS

Although APMR imaging is an useful noninvasive method to detect hypervascular liver tumors, APMR imaging is still not an alternative to CTA with respect to tumor detectability.

Control of expression by the cellulose synthase (bcsA) promoter region from Acetobacter xylinum BPR 2001

The 5' upstream region (about 3.1kb) of the cellulose synthase operon (bcs operon) has been isolated by cloning from Acetobacter xylinum strain BPR 2001. The expression level of the upstream region was determined using sucrose synthase cDNA as a reporter gene in the shuttle vector pSA19. The expression occurred with the 1.1-kb upstream sequence from the ATG start codon of the bcs operon but not with the 241-bp upstream sequence in A. xylinum, although neither the 1.1-kb nor the 241-bp upstream sequence caused any expression as a promoter in Escherichia coli. The level of expression with the 1. 1-kb upstream sequence in A. aceti was 75% of that in A. xylinum. These results suggest that the upstream region functions as a specific promoter for the Acetobacter genus. The expression was reduced by the introduction of the 241-bp upstream region between the lac promoter and the reporter gene in E. coli and was not detected in A. xylinum. This suggests that the short upstream region composed of 241bp contains the site(s) which causes a negative regulation on the transcription for bcs operon. The production of recombinant protein with the ribosome-binding site (RBS) of A. xylinum obtained from the bcs operon, was reduced to about half in E. coli, and that with the site of the lac promoter was also reduced to about half in A. xylinum. This shows that a species-specific predominance occurs during interaction between mRNA and 16S rRNA in the RBS between A. xylinum and E. coli.

Does potassium ion concentration affect lung preservation?

To evaluate the influence of potassium ion concentration in an organ preservation solution on lung preservation, four types of solutions were produced. These preservation solutions consisted of sodium and potassium ions on the cation and phosphate ions on the anion with glucose. Contents of solutions were: (1) 155 mmol/l Na+, 0 mmol/l K+; (2) 150 mmol/l Na+, 5 mmol/l K+; (3) 20 mmol/l Na+, 135 mmol/l K+; and (4) 0 mmol/l Na+, 155 mmol/l K+. All four solutions possessed the same osmolarity, the same pH in the same temperature, and the same buffer action. Lungs were preserved at 7 degrees C in these solutions for 24 h and evaluated in a rat lung perfusion system with perfluorochemical emulsion. Pressure-limited perfusions with pressure-limited ventilation were carried out for 20 min before and after preservation. Thereafter, the recovery ratios of pulmonary arterial flow (Q), tidal volume (VT), oxygen tension of the pulmonary venous effluent (PPVO2), and wet-to-dry ratios were compared. The recovery ratios of Q were better in low, but not zero, potassium solutions, whereas wet-to-dry ratios were kept lower in high potassium solutions. No difference in pulmonary compliance or gas exchange was observed against a great change in potassium ion concentration. Therefore, the potassium ion concentration did not play a major role in lung preservation.

Comparison of diets among elderly female residents in two suburban districts in Chiang Mai Province, Thailand, in dry season--survey on high- and low-risk districts of lung cancer incidence

By means of duplicate meals, we collected food samples of general female residents, aged 50 to 74 years at two suburban districts in Chiang Mai Province, which are distinguished by very high and low incidence rates of lung cancer. Then, on the basis of analyses of their consumption of foods by food groups, we compared their dietary habits in the dry season of northern Thailand with special reference to the difference in lung cancer incidence. In brief, the following features and difference in their dietary habits were found; 1) Rice, vegetables, and pork were most frequently eaten in both the districts. 2) Consumption of fruits, in both quantity and variety, at a high-risk district was much less than that at a low-risk district. 3) Female residents at a low-risk district consumed more variety of green and yellow vegetables than those at a high-risk district. 4). Potato was not found in food samples of a high-risk district. 5) confectionery was more prevalent in a low-risk district than at a high-risk district.

Effect of particles on sheep lung hemodynamics parallels depletion and recovery of intravascular macrophages

We previously showed in newborn lambs that the pulmonary hemodynamic responses to foreign particulate matter (liposomes; Monastral blue) developed in parallel with the maturation of the pulmonary intravascular macrophage system. We now report our use of the liposome-encapsulated heavy-metal-chelating agent dichloromethylene diphosphonate to deplete the intravascular macrophages of small lambs. Functionally and by quantitative histology, we depleted the vast majority of the intravascular macrophages (71% by Monastral blue particle retention, n = 22; 77% by histology; n = 2). Depletion success increased to > 90% as we optimized the liposome-depletion regime. Recovery of the lung hemodynamic response began within 3 days. By 2 wk, the functional responses had fully recovered (n = 8), and, according to quantitative histology, the macrophage population (n = 2) had recovered 65%. Macrophage depletion in lambs is relatively inexpensive and easy to achieve. It is a safe procedure and is followed by full recovery in approximately 2 wk, provided that an aseptic technique is used to prevent bacteremia.

Significance of tumor vascularity as a predictor of long-term prognosis in patients with small hepatocellular carcinoma treated by percutaneous ethanol injection therapy

BACKGROUND/AIMS

We estimated the significance of the vascularity of small hepatocellular carcinoma (HCC) as a predictor of long-term prognosis in patients treated with percutaneous ethanol injection therapy (PEIT/PEI).

METHODS

Fifty-four patients who have been followed-up in our hospital and who had HCC less than 20 mm in diameter were observed for 199 to 2074 days. Hepatic angiography (digital subtraction angiography; DSA and ultrasound angiography with intraarterial CO2 microbubbles; USAG) was performed before treatment in all cases, and the vascularity of the tumor was clinically evaluated. The survival rate was analyzed according to this vascularity.

RESULTS

Of the 54 tumors, 24 had tumor stain on DSA, while 30 did not, and 38 showed enhancement on USAG, while 16 did not. The 3- and 5-year survival rates were 48.7 and 34.1% and 89.7 and 69.7% of patients with negative staining HCC (p = 0.0723). The rates were 48.6 and 36.7%, respectively, of patients with positive enhancement HCC on USAG, and both rates were 85.7% of patients with negative enhancement HCC (p = 0.0231).

CONCLUSIONS

Tumor vascularity will play a role in the long-term prognosis of these patients with small HCC when they are treated with PEIT/PEI.

Significance of early measurement of serum hepatitis C virus RNA in predicting response to interferon therapy in patients with chronic hepatitis C

BACKGROUND

Interferon can induce complete clearance of hepatitis C virus (HCV) in some patients with chronic hepatitis C. However, various side effects often require cessation of administration during the treatment period. Early prediction of response to interferon would be helpful. We evaluated measurement of serum HCV RNA 2 weeks after starting interferon as a predictor of response.

METHODS

The presence of HCV RNA was measured in serum 2 weeks after starting therapy in 85 patients receiving natural interferon a (total 480 MU).

RESULTS

Twenty-seven of 38 patients (71.1%) in whom serum HCV RNA had disappeared at 2 weeks achieved a sustained response. Only two out of 47 patients (4.3%) in whom serum HCV RNA had not disappeared at 2 weeks achieved a sustained response. Of 42 patients with pre-treatment HCV RNA concentrations less than 1 x 10(6) eq/ml, 26 of 30 patients (86.7%) whose HCV RNA had disappeared at 2 weeks achieved a sustained response, while only one of 12 patients (8.3%) whose HCV RNA was still detectable at 2 weeks had a sustained response.

CONCLUSION

Clearance of serum HCV RNA after 2 weeks of treatment with interferon was more likely in patients with lower pre-treatment HCV RNA concentrations and they had a high likelihood of achieving a sustained response. In patients in whom serum HCV RNA was still detectable after 2 weeks of interferon therapy, a sustained response was most unlikely.

Structural study of an exocellular polysaccharide of Bacillus circulans

Bacillus circulans, a soil bacterium, produced an exocellular polysaccharide of high viscosity. On the basis of the results of methylation analysis, mild acid hydrolysis, and 1D and 2D 1H-NMR spectroscopy, it was concluded that the polysaccharide has a basic repeating unit composed of beta-L-rhamnopyranose, alpha-D-mannopyranose, alpha-D-galactopyranose, and alpha-D-glucopyranuronic acid with the following structure. [symbol: see text]

Patterns of recurrence after initial treatment in patients with small hepatocellular carcinoma

To assess intrahepatic metastasis (IM) and multicentric occurrence (MO) after initial treatment of small hepatocellular carcinomas (HCC) < or = 2 cm in diameter, we performed clinical and pathological studies in 112 patients who underwent percutaneous ethanol injection therapy (PEIT) or hepatic resection for HCC from January 1985 to December 1994. Patients with intrahepatic recurrences were classified into two groups based on the type of recurrence: the IM group (n = 29, 50.9%) and the MO group (n = 28, 49.1%). Overall recurrence rates after initial treatment were 23.7% at 1 year, 64.5% at 3 years, and 76.1% at 5 years. In patients with IM, the majority of intrahepatic recurrences were observed within 3 years of initial treatment and the primary HCC lesions were closely related to the degree of tumor cell differentiation. Alternatively, intrahepatic recurrences occurred throughout the follow-up period in patients with MO, and the evidence of underlying liver disease (anti-HCV [antibody to hepatitis C virus] positive) and elevated serum alfa-fetoprotein (AFP) concentrations were closely associated with intrahepatic recurrence. Prognoses following additional treatment in MO group patients were superior to those in IM group patients. These results suggest that differentiation between IM and MO in patients with HCC is important for understanding the development and biological behavior of the tumor. That is, the early detection of intrahepatic recurrence and the institution of appropriate additional therapy (PEIT or hepatic resection) may prolong survival in patients with MO.

Quasispecies nature of hepatitis C virus and response to alpha interferon: significance as a predictor of direct response to interferon

BACKGROUND/AIMS

We evaluated the significance of the quasispecies nature of HCV as a predictor of the response to alpha interferon therapy in patients with chronic hepatitis C.

METHODS

Natural alpha interferon was administered in 62 patients for 24 weeks (daily for 2 weeks, then three times weekly for 22 weeks) and factors were analyzed that could affect the response. HCV subtype, HCV RNA concentrations and the number of HCV quasispecies were evaluated before treatment. HCV RNA concentrations were measured by branched DNA probe assay. The number of HCV quasispecies was measured by fluorescence single-strand conformation polymorphism analysis.

RESULTS

The HCV RNA concentration (p < 0.0001), HCV subtype (p = 0.0076), and the number of HCV quasispecies (p = 0.0024) were significantly associated with a complete response. Multivariate analyses showed that the number of HCV quasispecies was an independent predictor of the disappearance of HCV RNA during the administration of alpha interferon, but did not predict a relapse after its completion. Pretreatment concentration of HCV RNA was the only factor that was related to a long-term disappearance of HCV RNA.

CONCLUSIONS

The number of HCV quasispecies was significantly related to the response to alpha interferon early in its administration. The pretreatment concentration of HCV RNA was mainly related to a relapse following completion of treatment.

Patterns of recurrence after initial treatment in patients with small hepatocellular carcinoma

To assess intrahepatic metastasis (IM) and multicentric occurrence (MO) after initial treatment of small hepatocellular carcinomas (HCC) < or = 2 cm in diameter, we performed clinical and pathological studies in 112 patients who underwent percutaneous ethanol injection therapy (PEIT) or hepatic resection for HCC from January 1985 to December 1994. Patients with intrahepatic recurrences were classified into two groups based on the type of recurrence: the IM group (n = 29, 50.9%) and the MO group (n = 28, 49.1%). Overall recurrence rates after initial treatment were 23.7% at 1 year, 64.5% at 3 years, and 76.1% at 5 years. In patients with IM, the majority of intrahepatic recurrences were observed within 3 years of initial treatment and the primary HCC lesions were closely related to the degree of tumor cell differentiation. Alternatively, intrahepatic recurrences occurred throughout the follow-up period in patients with MO, and the evidence of underlying liver disease (anti-HCV [antibody to hepatitis C virus] positive) and elevated serum alfa-fetoprotein (AFP) concentrations were closely associated with intrahepatic recurrence. Prognoses following additional treatment in MO group patients were superior to those in IM group patients. These results suggest that differentiation between IM and MO in patients with HCC is important for understanding the development and biological behavior of the tumor. That is, the early detection of intrahepatic recurrence and the institution of appropriate additional therapy (PEIT or hepatic resection) may prolong survival in patients with MO.

[Peri- and postoperative courses in patients undergoing concomitant cardiac and pulmonary operations]

We studied peri- and postoperative courses in patients undergoing concomitant cardiac and pulmonary operations (CCPO), which included pulmonary resection and coronary artery bypass grafting (CABG). Of eight patients who had lung cancer and ischemic heart disease (IHD), six underwent CCPO and two patients first had percutaneous transluminal coronary angioplasty (PTCA) followed by lung surgery at an interval after the first procedure. Twelve patients with lung cancer who underwent only pulmonary surgery and 13 patients with IHD who were treated with CABG were studied as controls. We compared peri- and postoperative characteristics among these groups of patient. Operating time, bleeding volume during surgery, amount of drainage discharge within 24 hours after the operation, and ICU days were significantly increased in the CCPO group in comparison with the two control groups. In the CCPO group, mechanical ventilatory support time and administration days after the operation were significantly increased in comparison with the lung operation group, but not in comparison with CABG group. The two patients who sequentially underwent PTCA and lung surgery had postoperative courses similar to the CCPO patients. All CCPO patients were ambulatory upon discharge. None of the CCPO patients died from postoperative complications involving the respiratory tract or the circulatory system. Our data suggest that CCPO is available for patients with both heart and lung diseases when complications can be avoided by appropriate management, although these procedures are extremely invasive. We believe that CCPO should be attempted in patients with definite indications for such a procedure.