Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Identification and characterization of a GDSL lipase-like protein that catalyzes the ester-forming reaction for pyrethrin biosynthesis in Tanacetum cinerariifolium- a new target for plant protection

Although natural insecticides pyrethrins produced by Tanacetum cinerariifolium are used worldwide to control insect pest species, little information is known of their biosynthesis. From the buds of T. cinerariifolium, we have purified a protein that is able to transfer the chrysanthemoyl group from the coenzyme A (CoA) thioester to pyrethrolone to produce pyrethrin I and have isolated cDNAs that encode the enzyme. To our surprise, the active principle was not a member of a known acyltransferase family but a member of the GDSL lipase family. The recombinant enzyme (TcGLIP) was expressed in Escherichia coli and displayed the acyltransferase reaction with high substrate specificity, recognized the absolute configurations of three asymmetric carbons and also showed esterase activity. A S40A mutation in the Block I domain reduced both acyltransferase and esterase activities, which suggested an important role of this serine residue in these two activities. The signal peptide directed the localization of TcGLIP::enhanced green fluorescent protein (EGFP) fusion, as well as EGFP, to the extracellular space. High TcGLIP gene expression was observed in the leaves of mature plants and seedlings as well as in buds and flowers, a finding that was consistent with the pyrethrin I content in these parts. Expression was enhanced in response to wounding, which suggested that the enzyme plays a key role in the defense mechanism of T. cinerariifolium.

Development of Silafluofen-Based Termiticides in Japan and Thailand

With the advancement from natural pyrethrins to synthetic pyrethroids, their applications have expanded from household insecticides for indoor use against sanitary pests to outdoor use for agriculture, forestry, animal health, termite control, and many other pest situations. However, high fish toxicity and development of pyrethroid resistance in some pests have been cited as common shortcomings of pyrethroids. To overcome these pyrethroid problems such as high fish toxicity, Katsuda and fellow scientists invented silafluofen by introducing a silicone atom into the pyrethroidal chemical structure in 1984. In addition to the high insecticidal activity and low mammalian toxicity, this compound features low fish toxicity, chemical stability under sunlight, in the soil and under alkaline environments. These features make silafluofen unique among pyrethroids. In Japan, silafluofen has been used as an agricultural insecticide for 15 years since 1995 for various plants, especially useful for paddy rice protection because of its low fish toxicity. Over the last 20 years, silafluofen-based termiticides including emulsifiable concentrate (EC) and oil formulations have been widely used in Japan for soil treatment and timber treatments. Additional silafluofen product lines include anti-termitic plastic sheets which are laid under buildings. In this paper, literature on the development of silafluofen and its use in Japan are reviewed. On the other hand, in Thailand, we proceeded with development works of silafluofen-based termiticides from 2005 by starting laboratory efficacy tests and field efficacy tests in Phuket. Both laboratory and field tests showed good efficacy as a soil termiticide, suggesting that the material will perform well for commercial use in high biological hazard environments such as Thailand and can be used in environments close to water where fish toxicity might be a concern with other pyrethroids.

Specific regulation of pyrethrin biosynthesis in Chrysanthemum cinerariaefolium by a blend of volatiles emitted from artificially damaged conspecific plants

Plants emit specific blends of volatile organic compounds (VOCs) in response to mechanical wounding. Such induced VOCs have been shown to mediate in plant and interplant communication, yet little is known about the time- and dose-response relationships in VOC-mediated communications. Here, we employed young seedlings of Chrysanthemum cinerariaefolium to examine the effects of volatiles emitted by artificially damaged seedlings on the biosynthesis of the natural insecticides pyrethrins in intact conspecific plants. Wounded leaves emitted (Z)-3-hexenal, (E)-2-hexenal, (Z)-3-hexen-1-ol, (Z)-3-hexen-1-yl acetate and (E)-β-farnesene as dominant wound-induced VOCs. Exposing intact seedlings to a mixture of these VOCs at concentrations mimicking those emitted from wounded seedlings, as well as placing the intact seedlings next to the wounded seedlings, resulted in enhanced pyrethrin contents in the intact seedlings. Thus we quantified mRNA transcripts of 1-deoxy-D-xylulose 5-phosphate synthase (DXS), chrysanthemyl diphosphate synthase (CPPase), 13-lipoxygenase (13-LOX) and allene oxide synthase (AOS) genes in intact seedlings exposed to the VOC mixture to show that DXS and 13-LOX gene expression reached a maximum at 3 h, whereas CPPase and AOS reached it at 6 h. Interestingly, both increasing and decreasing the VOC mixture concentrations from those observed on injury reduced the expression of DXS, CPPase and AOS genes to the control level. Also, separating the VOC mixture into individual components eliminated the ability to enhance the expression of all the biosynthetic genes examined. This is the first study showing that the wound-induced VOCs function as a blend to control the biosynthesis of second metabolites at specific concentrations.

Progress and future of pyrethroids

After the chemical structure of "natural pyrethrins," the insecticidal ingredient of pyrethrum flowers, was elucidated, useful synthetic pyrethroids provided with various characteristics have been developed by organic chemists throughout the world, leading to the advancement of pyrethroid chemistry. Even in pyrethroids with high selective toxicity, a chemical design placing too much importance on efficacy improvements may invite loss of the safety margin. It is strongly hoped that the development of household pyrethroids and their preparations for use in living environments around humans and pets will be achieved in the future by retaining the characteristics of natural pyrethrins.

Control of mosquito vectors of tropical infectious diseases: (3) susceptibility of Aedes aegypti to pyrethroid and mosquito coils

We collected 11 groups of Aedes aegypti mosquitoes from various locations of Thailand. After rearing in the laboratory, the colonies were tested for KT50 values to dl,d-T80-allethrin 0.5% mosquito coils in a 25 m3 room semi-field test and KD50 and LD50 values to dl,d-T80-allethrin by a topical application method. Two groups of mosquitoes were susceptible to allethrin similar to a SS (known allethrin sensitive) group, and other 9 groups showed various levels of lower susceptibility to allethrin; of these 6 had susceptibilities similar to a BS (known allethrin resistant) group with extremely low susceptibility, while the remaining 3 groups had susceptibilities to allethrin between the SS and BS groups. The KD50 values with the topical application were found to correlate highly with the KT50 values in the 25 m3 room semi-field test, providing a useful test method for insect susceptibility evaluation. The allethrin mosquito coils, even at higher concentrations, had no activity against the 6 decreased susceptibility groups, similar to the BS group. With the 25 m3 room semi-field test, mosquito coils with d,d-T-prallethrin at concentrations of 0.1 to 0.15% plus a synergist and those with methoxymethyl-tetrafluorobenzyl tetramethylcyclopropane carboxylate (K-3050) at a concentration of 0.1% plus a synergist were found to be highly effective against these mosquito groups. These two pyrethroids had smaller KD50 and LD50 values for topical application, and were more effective than dl,d-T80-allethrin, having the potential to control Ae. aegypti mosquitoes with low allethrin susceptibility.

Control of mosquito vectors of tropical infectious diseases: (2) pyrethroid susceptibility of Aedes aegypti ( l) collected from different sites in Thailand

Four strains (SS, BS, A and B) of Aedes aegypti collected from different sites in Bangkok and at different times were examined for their pyrethroid susceptibility. Mosquito coils containing dl, d-T80-allethrin, d, d-T-prallethrin and methoxymethyl-tetrafluorobenzyl tetramethyl-cyclopropanecarboxylate (K-3050) with or without a synergist were tested by the 25 m3 semi-field test method. One strain (SS) was the most susceptible with KT50 values of about < 30 minutes for all mosquito coils, while the other three strains (BS, A and B) were found to be around 10 to 20 times more tolerant to pyrethroids than the SS strain. A similar tendency for the pyrethroid susceptibility of the four strains was obtained with tests by topical application method. In field efficacy tests, mosquito coils with d, d-T-prallethrin 0.20% plus N-(2-ethylhexyl)bicycle-[2,2,1]- hept-5- ene-2,3-dicarboxyimide as a synergist exhibited a repellent effect of about 85%, while those with K-3050 0.10% plus the synergist exhibited a greater repellent effect of about 90%. In contrast, the repellent effect of commercial dl, d-T80-allethrin 0.20% coils was as low as about 50%. The d, d-T-prallethrin and K-3050 coils with the synergist were confirmed to be highly effective in repelling Ae. aegypti.

Control of mosquito vectors of tropical infectious diseases: (1) bioefficacy of mosquito coils containing several pyrethroids and a synergist

The bioefficacy of mosquito coils containing several pyrethroids were tested in a 25 m3 room against Culex pipiens quinquefasciatus, Aedes aegypti and Anopheles dirus. The test results were compared with tests against Culex pipiens pallens in Japan. Based on the KT50 values (the 50% knockdown time) of mosquito coils containing dl, d-T80-allethrin, d, d-T-prallethrin and methoxymethyl-tetrafluorobenzyl tetramethyl-cyclopropanecarboxylate (K-3050) at doses of 0.05-0.5% (w/w) with or without a synergist, the pyrethroid susceptibility of the four mosquito species was as follows: Cx. p. quinquefasciatus was several times more tolerant to pyrethroids than Cx. p. pallens, Ae. aegypti was a further several times more tolerant than Cx. p. quinquefasciatus, and An. dirus was more susceptible than Cx. p. pallens (KT50 value: about half of Cx. p. pallens). The order of their susceptibilities is common for pyrethroids. Mosquito coils containing d, d-T-prallethrin and K-3050 at doses of 0.05-0.2% (w/w) and N-(2-ethylhexyl)bicycle-[2,2,1]-hept-5-ene-2,3-dicarboxyimide as a synergist at a ratio of 2 times the active ingredient were highly effective against Ae. aegypti, the most important mosquito vector for dengue fever.

Biosynthesis of pyrethrin I in seedlings of Chrysanthemum cinerariaefolium

The biosynthetic pathway to natural pyrethrins in Chrysanthemum cinerariaefolium seedlings was studied using [1-13C]d-glucose as a precursor, with pyrethrin I isolated using HPLC from a leaf extract. The 13C NMR spectrum of pyrethrin I from the precursor-administered seedlings indicated that the acid moiety was biosynthesized from d-glucose via 2-C-methyl-d-erythritol 4-phosphate, whereas the alcohol moiety was possibly biosynthesized from linolenic acid.

Role of nitric oxide in regulation of coronary blood flow in response to increased metabolic demand in dogs with pacing-induced heart failure

The role of endothelium-derived nitric oxide (NO) in the metabolic control of coronary blood flow (CBF) in heart failure (HF) is poorly understood, so the present study investigated the effects of inhibitors of NO synthesis on the response of CBF to changes in myocardial oxygen consumption (MVO2) in dogs with HF produced by rapid ventricular pacing and in control dogs. The CBF, MVO2, and other hemodynamic parameters were measured in anesthetized animals. Before infusion of Nomega-nitro-L-arginine methyl ester (L-NAME), the increases in CBF and MVO2 during pacing tachycardia were not significantly different between the control and HF dogs. Intracoronary infusion of L-NAME did not alter the responses of CBF or MVO2 to pacing tachycardia in the control dogs, but in the HF dogs, it reduced the CBF response to pacing tachycardia without altering the tachycardia-induced changes in MVO2. Intracoronary infusion of L-arginine reversed the effect of L-NAME. These results suggest that in HF dogs NO contributes to the regulation of CBF in response to an increased metabolic demand.

A new spontaneously diabetic non-obese Torii rat strain with severe ocular complications

A new spontaneously diabetic strain of the Sprague-Dawley rat was established in 1997 and named the SDT (Spontaneously Diabetic Torii) rat. In this research, we investigated the characteristics of the disease condition in the SDT rats. The time of onset of glucosuria was different between male and female SDT rats; glucosuria appeared at approximately 20 weeks of age in male rats and at approximately 45 weeks of age in female rats. A cumulative incidence of diabetes of 100% was noted by 40 weeks of age in male rats, while it was only 33.3% even by 65 weeks of age in female rats. The survival rate up to 65 weeks of age was 92.9% in male rats and 97.4% in female rats. Glucose intolerance was observed in male rats from 16 weeks of age. The clinical characteristics of the male SDT rats were (1) hyperglycemia and hypoinsulinemia (from 25 weeks of age); (2) long-term survival without insulin treatment; (3) hypertriglyceridemia (by 35 weeks of age); however, no obesity was noted in any of the male rats. The histopathological characteristics of the male rats with diabetes mellitus (DM) were (1) fibrosis of the pancreatic islets (by 25 weeks of age); (2) cataract (by 40 weeks of age); (3) tractional retinal detachment with fibrous proliferation (by 70 weeks of age) and (4) massive hemorrhaging in the anterior chamber (by 77 weeks of age). These clinical and histopathological characteristics of the disease in SDT rats resemble those of human Type 2 diabetes with insulin hyposecretion. In conclusion, SDT rat is considered to be a potentially useful model for studies of diabetic retinopathy encountered in humans.

New classification of small pulmonary nodules by margin characteristics on high-resolution CT

PURPOSE

To analyze margin characteristics of pulmonary nodules on high-resolution CT (HRCT) in order to improve imaging diagnoses.

MATERIAL AND METHODS

HRCT images of 193 pulmonary nodules of less than 30 mm maximum diameter (113 primary cancers, 15 metastatic cancers, 55 inflammatory nodules, and 10 benign tumors) were reviewed and classified as to 6 types of margins: round, lobulated, densely spiculated, ragged, tentacle or polygonal and halo. The relationships of these imaging types to the diagnoses, the underlying pathological features, mainly those of tumor growth patterns in 93 neoplasms, and the pathological characteristics of 14 inflammatory nodules were investigated.

RESULTS

Eighty-two percent of the lobulated, 97% of the densely spiculated, 93% of the ragged and 100% of the halo nodules were malignant. Eighty percent of the tentacle or polygonal nodules were inflammatory and 66% of the round ones were benign. The 6 types differed statistically as to the nature of the benignity/malignancy (p<0.001). Pathologically, in case of neoplasms, most of the 6 types had a relationship to a particular tumor growth pattern.

CONCLUSION

This HRCT classification method is useful for determining the nature of small pulmonary nodules and reflects the underlying pathological characteristics.

HLA class I and class II expression of pulmonary adenocarcinoma cells and the influence of interferon gamma

BACKGROUND

The clinico-biological significance of HLA (both class I antigen and class II one) expressed on tumor cells still remains controversial.

METHODS

Tumor cells were freshly separated from 33 surgical specimens of pulmonary adenocarcinoma. The tumor cells were incubated for 24 h in the presence or absence of IFN-gamma (130 International Units/ml). After incubation, the cells were cytocentrifuged onto glass slides and immunostained with either an anti-HLA class I (A, B, C) monoclonal antibody or anti-HLA class II (DR) one.

RESULTS

In 22 of 33 cases (66.7%), the HLA class I were individually expressed by more than 60% of tumor cells while so were the HLA class II in 15 (45.4%). No significant correlation was observed between the HLA class I expression and the HLA class II one. The proportion of HLA class I-positive tumor cells correlated with neither the grade of histological differentiation nor the stage of disease. In contrast, the proportion of HLA class II-positive tumor cells correlated with both the grade of histological differentiation and the stage. In most cases, IFN-gamma was found to increase the proportion of class II-positive tumor cells as well as that of class I-positive cells.

CONCLUSIONS

The above findings thus suggested that the HLA class II expression might therefore represent a manifestation of cellular differentiation and that IFN-gamma may, as a result, have the potential to differentiate cancer cells.

Angiopathies in pancreatic diabetes resulting from chronic pancreatitis

CONCLUSION

Marked diabetic micro- and macroangiopathies were recognized in three autopsy cases with pancreatic diabetes resulting from chronic pancreatitis.

BACKGROUND

Recent reports have suggested that diabetic retinopathy occurs as one of the microangiopathies in patients with secondary diabetes following chronic pancreatitis.

METHODS

We report three autopsy cases with pancreatic diabetes. Cases 1 and 2 showed alcoholic chronic pancreatitis. Case 3 was a patient with chronic pancreatitis resulting from hyperparathyroidism. All three cases had pancreatic calcification and markedly decreased exocrine pancreatic function. There was no family history of diabetes in these patients. The HbA1 values were elevated, with diminished secretion of both insulin and glucagon.

RESULTS

The common features of the clinical courses were poor glycemic control, including insulin-induced hypoglycemic attacks in the early stage and microangiopathy, followed by difficulties in treatment for hypertension in the late stage of pancreatic diabetes. Autopsies, performed after 12-18 yr of diabetes, revealed fibrosis of the pancreas, disappearance of acinar cells in the exocrine pancreas, atrophy, a diminished number of islets of Langerhans, and diabetic glomerulosclerosis, with arteriosclerosis in the brain, heart, and kidneys. Cerebral hemorrhage, heart failure, and myocardial infarction were suggested to be the main causes of death. Although the serum lipid levels were rather low in cases 1 and 2, arteriosclerosis was marked by the age of 60, and serum protein levels were also low in all three cases.

Diagnosis of visceral pleural invasion in resected lung cancer using a jet stream of saline solution

BACKGROUND

Visceral pleural invasion by the tumor is an important prognostic factor in patients undergoing resection for lung cancer. We developed a method to detect more accurately the presence of visceral pleural invasion in resected lung cancer.

METHODS

The surface of the visceral pleura over 90 resected peripheral tumors was irrigated twice with a jet stream of saline solution using a 20-mL syringe with a 21-gauge needle, and then the fluid, which contained desquamated cells, was collected for cytologic analysis. When cancer cells were found in the collected fluid, the tumor was judged to have invaded the visceral pleura.

RESULTS

Thirty-eight (42%) resected tumors were identified as having visceral pleural invasion either by our new method or by pathologic examination. Twenty-four cases were detected by the jet stream of saline method alone, 5 by pathologic examination alone, and 9 by both techniques. The sensitivity and accuracy of the two approaches in the diagnosis of visceral pleural invasion were 87% and 94%, respectively, for our new method, and 37% and 73%, respectively, for pathologic examination (p < 0.0001). Furthermore, among 38 patients who had a tumor demonstrating visceral pleural invasion, 5 (13%) and 9 (24%) patients, respectively, had cancer cells in the pleural effusion and intrapleural lavage fluid.

CONCLUSIONS

Our findings suggest that our method is useful in detecting cancer invasion of the visceral pleura, which is considered one of the causes of malignant effusion.

Solitary amyloid nodule in the lung

A rare case of solitary nodular amyloidosis of the lung is presented. As the nodule was clinically observed to enlarge, neoplastic disease was strongly suspected. Histologic study of the resected specimen, however, revealed an amyloid nodule. Three years postoperatively there has been no recurrence.

Species difference in protoporphyrin IX accumulation produced by an N-phenylimide herbicide in embryos between rats and rabbits

There was a remarkable species difference in developmental toxicity exhibited by S-53482, an N-phenylimide photobleaching herbicide, between rats and rabbits. S-53482 showed embryolethality, teratogenicity, and growth retardation in rats. In contrast, no developmental toxicity was shown in rabbits. The herbicidal activity of S-53482 is due to the photodynamic action of accumulated protoporphyrin IX (PPIX) as a result of inhibition of protoporphyrinogen oxidase (PPO), which is one of the key enzymes in porphyrin biosynthesis common to both plants and animals as part of chlorophyll and heme synthesis. Some plant PPO inhibitors were reported to inhibit mammalian PPO. Therefore, in a search for a possible link between developmental toxicity and enzyme inhibition, PPIX accumulations presumably resulting from PPO inhibition in rat and rabbit embryos were investigated. The results demonstrated that PPIX concentration was increased in rat embryos by 2 orders of magnitude when compared to that of nontreated embryos. On the other hand, no PPIX was accumulated in rabbit embryos even by treatment with a high dose level of S-53482. It was concluded that the species difference in PPIX accumulation corresponded very well to that of the developmental toxicity exhibited by S-53482.

[Pulmonary metastatic carcinoma of the rectum growing extensively in the bronchial lumen--a case report]

A 75-year-old man secondly developed a solitary pulmonary metastatic carcinoma of the rectum, who had undergone an operation for the first pulmonary metastatic disease in the left upper division segment before three years. The second tumor was about 2.0 cm in diameter, and located in the central area of the left lower lobe. At the time of operation, the tumor was found at the roots of both the B8 and the B9 bronchi, and thus removed by the basal segmentectomy. The resected specimen showed an endobronchial growth of metastatic adenocarcinoma in both the B8 and the B9 bronchi. Especially in the lumen of the B9 bronchus, the tumor dendritically extended from the central portion to the peripheral portion. The growing pattern of the tumor was very unique, and gave us attention to the extension of resection for metastatic lung carcinoma.

Role of endothelium-derived nitric oxide in coronary vasodilatation induced by pacing tachycardia in humans

Endothelium-derived NO contributes to the control of coronary perfusion. We investigated the roles of NO in the metabolic coronary vasodilatation induced by rapid pacing in humans. We evaluated the dilatation of large epicardial and resistance coronary arteries during rapid atrial pacing before and after intracoronary infusion of NG-monomethyl-L-arginine (L-NMMA), an inhibitor of NO synthesis, in 19 patients without significant coronary artery disease. The diameter of the large epicardial coronary artery and coronary blood flow (CBF) were assessed by quantitative coronary arteriography and by a Doppler flow velocity measurement. An increase in the heart rate increased CBF (P < .01) and the coronary artery diameter (P < .05). L-NMMA at a total dose of 200 mumol reduced basal CBF but did not significantly affect basal coronary artery diameter, arterial pressure, or heart rate. L-NMMA inhibited the pacing-induced dilatation of the large coronary arteries (P < .05) but did not affect pacing-induced increases in CBF. L-NMMA inhibited the acetylcholine-induced increase in CBF (P < .01) and acetylcholine-induced dilatation of the large epicardial coronary artery (P < .05). These results show that the contribution of NO to the metabolic vasodilatation during rapid pacing may differ between large epicardial and resistance coronary arteries in patients without significant coronary artery disease.

ATP-sensitive K+ channel opener pinacidil augments beta 1-adrenoceptor-induced coronary vasodilation in dogs

The opening of ATP-sensitive K+ (K+ATP) channels contributes to the mechanism of metabolic coronary vasodilation. The aim of the present study was to determine whether K+ATP channel opener pinacidil augments coronary vasodilation induced by beta-adrenoceptor stimulation. In anesthetized dogs, coronary vasodilation in response to intracoronary infusion of a beta 1-adrenoceptor agonist denopamine, selective beta 2-adrenoceptor stimulation with isoproterenol after bisoprolol or nitroglycerin was studied before and during simultaneous intracoronary infusion of pinacidil at a dose of 1 microgram/min, which had no effect on basal hemodynamics. Pinacidil augmented the denopamine-induced increase in coronary blood flow (CBF) from 38 +/- 9 to 66 +/- 16% (P < 0.05) but did not affect the denopamine-induced by isoproterenol or nitroglycerin. Thus pinacidil selectively augmented beta 1-adrenoceptor-mediated coronary vasodilation. These observations suggest that the K+ATP channel opener pinacidil may increase myocardial perfusion during metabolic stress associated with beta 1-adrenoceptor stimulation.

Basal release of endothelium-derived nitric oxide at site of spasm in patients with variant angina

OBJECTIVES

The aim of this study was to investigate the basal release of nitric oxide at spastic sites in patients with variant angina.

BACKGROUND

We previously reported that endothelium-dependent dilator responses to acetylcholine, substance P and bradykinin are preserved at the site of coronary artery spasm. However, it is not known whether the basal release of endothelium-derived nitric oxide is altered at the spastic site.

METHODS

The effects of intracoronary N(G)-monomethyl-L-arginine (L-NMMA, an inhibitor of nitric oxide synthesis) at cumulative doses of 50, 100 and 200 micromol on basal coronary artery tone were investigated in eight patients with variant angina and normal coronary angiograms and in eight control subjects. The lumen diameters of large epicardial coronary arteries were assessed by quantitative coronary arteriography.

RESULTS

Coronary spasm was provoked by the intracoronary administration of acetylcholine in all patients with variant angina. L-NMMA did not alter the arterial pressure and heart rate but significantly decreased the coronary artery diameter at spastic and nonspastic sites. Constrictive responses to L-NMMA were significantly greater (p < 0.01) at the spastic site (constriction by 200 micromol, 22+/-7%, mean +/- SD) than at the nonspastic site (10+/-7%). Constrictive responses to L-NMMA at the nonspastic site in patients with variant angina were comparable to those in the control subjects.

CONCLUSIONS

These findings support the hypothesis that the basal release of nitric oxide may not be decreased at the spastic site in patients with variant angina.

Endothelium-derived nitric oxide does not modulate metabolic coronary vasodilation induced by tachycardia in dogs

Endothelium-derived nitric oxide (EDNO) has been implicated in the modulation of coronary arterial tone. The aim of this study was to determine if metabolic coronary vasodilation induced by pacing tachycardia is altered by the inhibition of EDNO synthesis. Before and after the intracoronary infusion of an inhibitor of EDNO synthesis (N omega-nitro-L-arginine-methyl-ester, L-NAME), changes in coronary blood flow (CBF), regional myocardial blood flow (MBF), and myocardial oxygen consumption (MVO2) were measured in anesthetized dogs in response to atrial pacing tachycardia. Increasing the heart rate from 109 +/- 10 to 160 beats/min by pacing produced significant increases in CBF (p < 0.05), MVO2 (p < 0.05), and MBF in each sublayer of the myocardium (p < 0.05). L-NAME did not alter the pacing-induced increases in CBF, MVO2, or regional MBF. In addition, the ratio of the tachycardia-induced increase in CBF to the increase in MVO2 was not changed by L-NAME. The coronary vasodilation evoked by acetylcholine was attenuated by L-NAME (p < 0.05). However, the response to sodium nitroprusside was not altered. These results suggest that EDNO does not play a primary role in the mechanism mediating metabolic coronary vasodilation induced by pacing tachycardia in dogs.

Prognostic factors obtained by a pathologic examination in completely resected non-small-cell lung cancer. An analysis in each pathologic stage

We attempted to clarify what factors predominantly influence the survival of patients with non-small-cell lung cancer in each pathologic stage on the basis of information generally obtained by a pathologic examination of completely resected non-small-cell lung cancer. The subjects included 243 patients with stage I, 63 with stage II, and 108 with stage IIIA disease. Pathologic features used in the analysis were as follows: the greatest tumor size (< or = 3.0 cm versus > 3.0 cm), the histologic cell type (squamous versus nonsquamous cell carcinoma), the grade of differentiation, and tumor invasion of pleura and vessels. In stage IIIA, the extent of the metastasis to the lymph nodes was also included in the analysis. The significant prognostic factors (p < 0.05) in stage I demonstrated by a univariate analysis of the survival curves included the tumor size, the grade of differentiation (well differentiated versus moderately and poorly differentiated tumor), pleural involvement, and invasion of the artery and vein. In addition, the histologic cell type and the pleural involvement in stage II and invasion of the vein and the extent of metastasis to the lymph nodes (N0 and N1 versus N2) in stage IIIA were also found to be significant prognostic factors. A multivariate prognostic factor analysis showed that the grade of differentiation, pleural involvement, and venous invasion in stage I; the histologic cell type and pleural involvement in stage II; and venous invasion and mediastinal lymph node metastasis in stage IIIA were all predominant prognostic factors. These observations therefore suggest that a pathologic examination can identify the patients with a poor prognosis, which is different among the stages.

Collaborative assessment of optimal administration period and parameters to detect effects on male fertility in the rat: effects of cyclophosphamide on the male reproductive system

As part of a collaborative project to determine optimal administration period and parameters to detect compound effects on male fertility in the rat, adult male rats were administered cyclophosphamide daily at 5, 10, 20 and 40 mg/kg for 2 weeks, or at 2.5, 5 and 10 mg/kg for 4 or 9 weeks. After the pre-pairing administration period, each male was paired with an untreated female. After mating, testes and epididymides were removed and examined for organ weights, sperm head counts, sperm morphology and histopathology. Mated females were caesarean-sectioned on Day 13 of gestation. Although atrophy of epithelia in the cauda epididymides and decreases of spermatogenic cells in the testes were observed in the higher dose groups in the 2w study, no other effects on the male reproductive system were noted in any of the studies. There were clear effects on pregnancy outcome; implantation efficiency was decreased in the highest dosage groups and postimplantation losses increased in all the dosage groups in all studies. These results suggest that a fertility study with females is needed particularly in the case of mutagenic agents, together with a detailed histopathological evaluation for reliable detection of toxicity on the male reproductive system.

Glibenclamide, a selective inhibitor of ATP-sensitive K+ channels, attenuates metabolic coronary vasodilatation induced by pacing tachycardia in dogs

BACKGROUND

We previously reported that glibenclamide (a selective inhibitor of ATP-sensitive K+ channels [K+ATP channels]) inhibited metabolic coronary vasodilatation induced by beta 1-adrenoceptor stimulation. However, the role of K+ATP channels in metabolic coronary vasodilatation induced by tachycardia is still unknown. This study aimed to determine whether glibenclamide attenuates metabolic coronary vasodilatation induced by pacing-induced tachycardia.

METHODS AND RESULTS

In anesthetized dogs, increasing heart rate from 103 +/- 1 to 160 beats per minute with atrial pacing increased coronary blood flow without altering arterial pressure and left ventricular pressure. Intracoronary infusion of glibenclamide at 1.5 and 5.0 micrograms.kg-1.min-1 did not alter basal coronary blood flow but significantly attenuated (P < .01) the tachycardia-induced coronary vasodilatation without altering the tachycardia-induced increase in myocardial oxygen consumption (MVO2). In conscious dogs, intracoronary glibenclamide at 5.0 micrograms.kg-1.min-1 attenuated (P < .05) coronary vasodilatation induced by ventricular pacing from 85 +/- 6 to 150 beats per minute. Glibenclamide markedly attenuated coronary vasodilation evoked with the K+ATP channel opener pinacidil.

CONCLUSIONS

These data indicate that blockade of coronary vascular K+ATP channels with glibenclamide inhibited metabolic coronary vasodilatation induced by pacing tachycardia in dogs, suggesting that K+ATP channels are involved in the mechanism mediating metabolic coronary vasodilatation associated with pacing tachycardia.

New rhodomycin analogs, SS-288A and SS-288B, produced by a Streptomyces violaceus A262 mutant

Two new rhodomycin metabolites, SS-288A and SS-288B, were specifically produced by a blocked mutant obtained from Streptomyces violaceus A262 and were respectively identified as 7,10-di(O-rhodosaminyl-deoxyfucosyl-deoxyfucosyl)-beta -rhodomycinone and -beta-isorhodomycinone.

The correlation between tumor size and lymphatic vessel invasion in resected peripheral stage I non-small-cell lung cancer. A potential risk of limited resection

We attempted to clarify whether a correlation exists between tumor size and the incidence of lymphatic vessel invasion in peripheral non-small-cell lung cancer without regional lymph node metastasis. The study included 212 resected non-small-cell lung cancers classified as pathologic stage I disease and located on the periphery of the lung. The incidence of lymphatic vessel invasion was relatively correlated with the maximum diameter of the tumor as follows: 25% (1/4) for tumor size 1.0 cm or less, 40% (19/48) for size 1.1 to 2.0 cm, 49% (28/58) for size 2.1 to 3.0 cm, and 57% (58/102) for tumor size 3.1 cm or more. The incidence of lymphatic vessel invasion of tumors measuring 3 cm or less in greatest dimension was 44% (48/110). The degree of lymphatic vessel invasion of 20 resected tumor samples measuring 3 cm or less in greatest diameter with hilar lymph node metastasis was also examined for comparison. This figure was as high as 85%. These observations suggest that even small peripheral tumors without any regional lymph node metastasis have a relatively high rate of lymphatic vessel invasion and thus pose a potential risk of local recurrence after a limited resection, especially in a wedge resection of the tumor.

ATP sensitive potassium channels are involved in adenosine A2 receptor mediated coronary vasodilatation in the dog

OBJECTIVE

The aim was to determine a role of ATP sensitive potassium (KATP) channels in adenosine A2 receptor mediated coronary vasodilatation in anaesthetised dogs in vivo.

METHODS

Coronary blood flow in the left circumflex coronary artery, aortic pressure, and left ventricular pressure were measured during intracoronary infusions of the drugs into the left circumflex artery.

RESULTS

A non-selective A2 receptor agonist NECA (5'-N-ethylcarboxamidoadenosine) at 10(-10)-10(-8) mol.min-1 before and after an A1 receptor antagonist DPCPX (8-cyclopentyl-1,3-dipropylxanthine) increased coronary blood flow in a dose dependent manner, without affecting other haemodynamic variables. Glibenclamide at 10 micrograms.kg-1.min-1, which did not alter baseline haemodynamic variables, markedly inhibited the increases in coronary blood flow caused by NECA alone and after DPCPX (p < 0.01). A non-selective adenosine receptor antagonist 8-phenyltheophylline abolished the NECA induced increases in coronary blood flow after DPCPX. These results suggest that A2 receptor mediated coronary vasodilatation was mediated largely by opening of KATP channels. Glibenclamide did not alter the increase in coronary blood flow evoked by forskolin or acetylcholine, suggesting that KATP channels may not be involved in coronary vasodilatation induced by activation of adenylate cyclase or guanylate cyclase. Furthermore, DPCPX increased basal coronary blood flow, which was blocked by 8-phenyltheophylline and by glibenclamide, suggesting that it may have unmasked A2 receptor mediated coronary vasodilatation by inhibiting the A1 receptor mediated vasoconstricting action of endogenous adenosine.

CONCLUSIONS

Opening of KATP channels may be involved importantly in adenosine A2 receptor mediated coronary vasodilatation in canine hearts.

Glibenclamide, a putative ATP-sensitive K+ channel blocker, inhibits coronary autoregulation in anesthetized dogs

We tested the hypothesis that ATP-sensitive K+ channels are involved in the mechanism mediating coronary autoregulation in open-chest dogs. We perfused the left anterior descending coronary artery with arterial blood from an extracorporeal circuit and measured steady-state coronary blood flow (CBF) with stepwise changes in coronary perfusion pressure (CPP) between 50 and 150 mm Hg during an intracoronary infusion of vehicle or glibenclamide (a putative blocker of ATP-sensitive K+ channels). CBF was relatively stable over CPP between 50 and 110 mm Hg during vehicle infusion, indicating the presence of autoregulation at the CPP range. During glibenclamide infusion (10 micrograms.min-1 x kg-1), CBF progressively decreased with reduction in CPP below 110 mm Hg, whereas the CPP-CBF relation at CPP above 110 mm Hg was not altered by glibenclamide. The autoregulation index [1-(delta F/F)/(delta P/P), where F indicates CBF and P indicates CPP] was greater than 0 over the CPP range between 50 and 100 mm Hg during vehicle infusion and was less than 0 during glibenclamide infusion. Glibenclamide did not alter systemic arterial pressure, heart rate, left ventricular pressure, and changes in regional myocardial oxygen consumption associated with changes in CPP. In the absence of glibenclamide, the CPP-CBF relation was reproducible in the repeated studies for time control. These results suggest that ATP-sensitive K+ channels play an important role in mediating coronary autoregulation at the lower range of CPP in the blood-perfused dog heart.

Benign breast disease as a breast cancer risk in Japanese women

A hospital-based retrospective cohort study of benign breast disease (BBD) as a risk factor of future breast cancer (BC) development was conducted. Four hundred and twenty-eight patients with biopsied BBD were followed-up for a median period of 8 years, together with age-matched women with normal breasts (normal control) and BC patients (cancer control), at the ratio of 1:2:2. Twenty-one breast cancers developed, 7 in the cases, 4 in the normal controls, and 10 in the BC controls, showing the relative risk (RR) with 95% confidence intervals (CI) to be 3.5 (1.03-11.9) in the cases with respect to the normal controls. The RR of the cases is not lower than that of contralateral breast cancer incidence. There were no significant differences in the risks of cancers in other organs among the groups. Pathological examination revealed that only atypical hyperplasia increased the RR of BC, as compared with the normal control breast group, or with non-proliferative disease. These results suggest that in a low-risk country, Japan, BBD is a definite risk factor for BC development as in high-risk countries.

Is T factor of the TNM staging system a predominant prognostic factor in pathologic stage I non-small-cell lung cancer ? A multivariate prognostic factor analysis of 151 patients

We attempted to clarify whether the T factor of the TNM staging system should be viewed as a predominant prognostic factor in patients with pathologic stage I non-small-cell lung cancer when analyzed together with various histopathologic factors and deoxyribonucleic acid ploidy pattern of tumors. We studied 151 patients who were in this stage. Histopathologic factors used in the analysis were as follows: histologic cell type (squamous or nonsquamous cell carcinoma), grade of differentiation, and tumor invasion of visceral pleura and vessels. Deoxyribonucleic acid ploidy pattern of tumors was analyzed by flow cytometry, and the tumors were classified as diploid or aneuploid tumors. Significant prognostic factors (p < 0.05) that were demonstrated by univariate analysis of survival curves were as follows: (1) T1 versus T2; (2) well versus moderately or poorly differentiated tumor; (3) the absence versus presence of tumor exposed on pleura, (4) artery invasion, (5) lymphatic vessel invasion; and (6) diploid versus aneuploid tumor. Multivariate prognostic factor analysis showed the grade of differentiation and deoxyribonucleic acid ploidy pattern to be predominant prognostic factors. The T2 tumor group had significantly more cases with tumor invasion of lymphatic vessels that did the T1 tumor group and included 18 cases with tumor exposed on pleura. When these two factors were excluded from multivariate analysis, the T factor was marginally significant (p = 0.08). These observations suggest that the T factor is not necessarily a predominant prognostic factor in pathologic stage I non-small-cell lung cancer.

Abnormality of background EEG determined by the entropy of power spectra in epileptic patients

Relationships between epileptiform discharges and background activity were examined by power spectral entropy (PSE), measuring a degree of EEG irregularity. The EEGs were recorded from 10 electrodes placed at F3, F4, C3, C4, T3, T4, P3, P4, O1 and O2 in 11 epileptic patients with widespread lateralized spike and wave complexes (SWCs). Bipolar records were also made from the antero-posterior derivations. The locations of the maximum PSE coincided with those of the maximum amplitude of SWC in most of the patients. Bipolar derivations with the maximum PSE always included the locations with the maximum PSE obtained from a linked ears reference. Pearson's correlation coefficient between PSE and SWC amplitude was 0.62 +/- 0.14 (mean +/- S.D.) in 11 patients, thus indicating that the scalp distribution of PSE was closely related to that of the amplitude of SWC. These findings suggest that the background EEG is disorganized in or near the epileptogenic focus. A focal background abnormality can therefore be estimated by PSE.

Quantification of EEG irregularity by use of the entropy of the power spectrum

A new method for quantifying irregularity of EEGs is proposed in this study. The entropy, an information measure, determines the uniformity of proportion distribution. The peakedness or flatness of the distribution of the EEG power spectrum, representing EEG rhythmicity, can be measured by the entropy, because the power spectrum consists of proportions of power at each frequency. The irregularity of the EEG was measured by the entropy of the power spectrum, called an irregularity index (II). The II was obtained from the power spectrum at F3, F4, C3, C4, P3, P4, O1 and O2 during rest and mental arithmetic in 10 normal subjects. Relative band powers of delta, theta, alpha and beta bands and alpha peak frequency were also obtained. EEGs during rest were significantly more irregular anteriorly than in the occipital areas. Alpha activity was also more irregular in the anterior region. A greater degree of EEG desynchronization during mental arithmetic was found over the left hemisphere and the right occipital area. The II was more sensitive to such desynchronization than alpha band power and alpha peak frequency. The differences in spectral structures between rest and mental arithmetic conditions, mainly over the left hemisphere, were also confirmed by the Kullback-Leibler information.

Mucoepidermoid carcinoma arising from a preexisting cyst of the liver

A case of mucoepidermoid carcinoma of the liver of a 46-year-old female is described. The resected mass from the left lobe of the liver measured 3 X 3 X 2 cm. The cut surface showed a well demarcated white, round shape, and a cystic formation measuring 1.8 X 1.4 cm was present in the center of the mass. Microscopically, the mass showed high-grade-type mucoepidermoid carcinoma, which consisted of squamous cells, mucus-producing cells, and glandular cells. The cystic wall was lined with apparently benign glandular, mucus-producing cells, squamous metaplastic cells, and tumor cells. The tumor was intimately contiguous with the cyst and gradual transition between tumor cells and cystic lining cells was recognized. It is suggested that the mucoepidermoid carcinoma of the liver in the present case was derived from malignant transformation of a preexisting cyst of the liver.

Immunoreactivity of surfactant-apoprotein in adenocarcinomas, large cell and small cell carcinomas of the lung

Fifty seven adenocarcinomas, 43 large cell and 30 small cell lung carcinomas were immunohistochemically examined using monospecific IgG against pulmonary surfactant apoprotein. Six peripheral adenocarcinomas and one peripheral large cell carcinoma were found to be histogenetically related to type II pneumocytes. They showed an acinar, papillary or solid growth pattern. The immunohistochemical study using anti-surfactant apoprotein IgG gave a granular reaction product in both the cytoplasm and nucleus of tumor cells whose intensity was variable. Intranuclear inclusions were generally the most densely stained structures. These results suggest that lung carcinomas derived from alveolar type II cells are found not only in bronchioloalveolar tumors, but are also found in other types of adenocarcinoma and in large cell carcinomas.

Mechanism of growth enhancement of 7,12-dimethylbenz[a]-anthracene-induced mammary tumors in rats given high polyunsaturated fat diet

The mechanism of growth enhancement of 7,12-dimethylbenz[a]anthracene (DMBA)-induced mammary tumors by high fat diet was investigated in 169 female Sprague-Dawley rats fed a semisynthetic diet containing 0, 8 or 40% corn oil by weight. The animals, most of which were intubated with 10 mg of DMBA twice during the 8th week of age, were fed an unsupplemented or fat-supplemented diet for 2 months from the 12th to the 21st week of age and finally killed during the 21st week of age. Compared to the rats fed a fat-free diet, a significantly increased yield of mammary adenocarcinoma with a shorter latency was observed in the rats fed a 40% corn oil diet. DNA synthesis of the biopsied mammary tumors more than 1 month after diet switch-over was estimated in terms of the rate of [3H]thymidine incorporation into the tissue. Significantly higher DNA synthesis of the mammary tumors biopsied from proestrous hosts was found, as compared with the tumors in similar hosts at other stages of the estrous cycle. The greatest enhancement of DNA synthesis in small and rapidly growing tumors was observed in the 40% corn oil diet group. Feeding with 40% corn oil diet always resulted in elevation of the weight percentage of linoleic acid in both simple lipids and phospholipids of the mammary tumors. These data indicate that the effects of dietary fat on mammary tumor growth might be mediated by the enhancement of tumor response to certain hormones, and that the enhanced responsiveness of tumors was associated with increased linoleic acid in tumor lipids.

Tubular adenoma with focal squamous metaplasia of the ascending colon

A case of tubular adenoma with focal squamous metaplasia of the ascending colon in a 66-year-old male is reported. The tumor was a pedunculated polyp with a size of 1.5 X 1.4 X 0.9 cm. Histologically, the tumor showed tubular adenoma with moderate to severe atypia, was accompanied by focal squamous metaplasia. It is thought that squamous epithelial polyp may be derived from colonic adenoma with squamous metaplasia, and that the malignant change of colonic adenoma with squamous metaplasia may lead to squamous cell carcinoma, adenosquamous carcinoma, and mucoepidermoid carcinoma. Only seven cases of colonic adenoma with squamous metaplasia have been reported previously in the literature, and it is yet necessary to discuss the histogenesis, significance, and natural history of colonic adenoma with squamous metaplasia.

[A case of carcinoma of the breast with squamous and cartilaginous metaplasia]

A 40 year-old female underwent mastectomy for a rapidly growing left breast mass. Histologically, the tumor was composed of invasive ductal carcinoma with squamous metaplasia, a cartilaginous component and a pleomorphic sarcoma-like component. In each histologic feature, gradual transition was recognized. A diagnosis of carcinoma with metaplasia (squamous and cartilaginous type) of the breast was made. The cartilaginous component in this case is probably the result of direct cartilaginous metaplasia of carcinoma cells and cartilaginous metaplasia followed upon carcinoma cells into small undifferentiated tumor cells and pleomorphic sarcomatous cells.

Tubular adenoma with squamous metaplasia of the sigmoid colon: a case report

A case of tubular adenoma with squamous metaplasia of the sigmoid colon in a 44-year-old female is reported. The tumor was a pedunculated polyp with a size of 1.2 X 1.7 X 1.7 cm. Histologically, the tumor showed tubular adenoma with focal squamous metaplasia. Borderline atypia was noted in a part of adenoma without squamous metaplasia and squamous component. It is supposed that squamous epithelial polyp, squamous cell carcinoma, adenosquamous carcinoma, and mucoepidermoid carcinoma may be derived from colonic adenoma with squamous metaplasia. Only six cases of the adenoma with squamous metaplasia of the large intestine have been reported previously in the literature.

[Primary amyloidosis associated with early gastric carcinoma(IIb like IIa type) diagnosed by preoperative gastric biopsy--a case report]

A case of primary amyloidosis associated with intramucosal adenocarcinoma of the stomach, diagnosed by preoperative biopsy, is reported. A 77-year-old man was admitted to our hospital with complaints of vertigo and general fatigue. X-ray and endoscopic examination revealed a IIb-like IIa type protruded lesion on the cardia of the stomach. A biopsy specimen from the protruded lesion disclosed well differentiated tubular adenocarcinoma and amyloid deposition. Partial gastrectomy was performed on August, 18, 1981. Upon histological study, a diagnosis of primary amyloidosis associated with intramucosal well differentiated tubular adenocarcinoma was made. We suggest that the histogenesis of this gastric carcinoma was related to the gastric lesion due to primary amyloidosis. Careful review of the Japanese literature disclosed that ours is the first case report of primary amyloidosis associated with early gastric carcinoma diagnosed by pre-operative gastric biopsy.

[Case of lipohyperplasia of the ileocecal valve with adenocarcinoma of the ascending colon]

A rare case of lipohyperplasia of the ileocecal valve contiguous with adenocarcinoma of the ascending colon is reported. The patient was a 67-year-old female with a chief complaint of muco-bloody stool. Barium enema X-ray study revealed a filling defect in the proximal portion of the ascending colon, suggestive of Borrmann II-type carcinoma and enlargement of the ileocecal valve. Ileocecotomy and right colectomy were performed. Histological examination disclosed that the tumor of the ascending colon consisted of well differentiated adenocarcinoma; the proliferation of fat tissue in the submucosa of the ileocecal valve was diagnosed as lipohyperplasia of the ileocecal valve. The histogenesis of this lipohyperplasia seems to be secondary development induced by the adenocarcinoma of the ascending colon.

[Adenoid cystic carcinoma of the breast--a case report]

We report a rare case of adenoid cystic carcinoma (ACC) of the breast. The patient was a 60-year-old female with a lump of the left breast which had present for 20 years. Macroscopically, the resected left breast tumor was well defined, 7.5 X 7 X 5 cm in size, oval shaped, yellowish gray-white and solid, parts of the tumor showed cystic appearance. Microscopic study revealed a cribriform pattern and alveolar proliferation of uniform, small cells forming cysts, and duct-like spaces which contained mucous content. Each tumor nest was surrounded by hyaline stroma. Alcian blue-PAS staining showed that the cysts were alcian blue-positive; the ducts were PAS-positive. The tumor was diagnosed as ACC of the breast.