F18-FDG-PET evaluation of patients for resection of colorectal liver metastases.

BACKGROUND/AIMS: Liver resection is the only treatment which offers long-term survival for patients with colorectal liver metastases. However, the significant mortality and morbidity associated with hepatectomy makes accurate patient selection paramount. Current staging by CT and MRI has limitations, with these modalities delivering a sensitivity and specificity of only 70-80%. Thus some patients may be deprived of long-term survival, and others subjected to futile surgery. METHODOLOGY: We report our experience of the influence of F18-FDG-PET scanning in the management of 31 consecutive patients with colorectal liver metastases referred for liver resection. RESULTS: F18-FDG-PET scanning detected liver and pulmonary metastases with a sensitivity of 96% and 100% respectively, in comparison to corresponding figures of 70% and 83% for CT. Furthermore, the sensitivity of F18-FDG-PET scanning in identifying extra-hepatic and extra-pulmonary disease was 100% in comparison to 20% for CT. Overall, F18-FDG-PET scanning resulted in a significant alteration of management in 29% of patients. CONCLUSIONS: F18-FDG-PET scanning has an important clinical impact on the management of patients being considered for resection of colorectal liver metastases.

Post-partum retreatment with iridium-192 wire brachytherapy for meningioma recurring in pregnancy.

We report the case history of a female patient who had received radical radiotherapy for a malignant meningioma at the age of 11 years. Thirteen years later, during her first pregnancy, she presented with a recurrence. The tumour was surgically debulked, but complications related to postoperative sepsis, the location of the tumour, and the extent of her previous treatment made the delivery of adjuvant radiotherapy problematic. The tumour bed was treated using an interstitial implant of 192Ir wires to a dose of 60 Gy in 100 hours. The patient remains well with no evidence of tumour recurrence or brain necrosis 2 years later. We discuss the role of female sex hormones in meningioma and the difficulties of radical retreatment of tumours in the central nervous system. The various techniques of brachytherapy in the brain are highlighted. The specific advantages of 192Ir in this patient are discussed.

Complete pathological response to chemotherapy for non-small cell lung cancer demonstrated by gamma camera positron emission tomography.

We report the case history of a 61-year-old female smoker who presented with an inoperable T2N2M0 squamous cell carcinoma of the right upper lobe bronchus. This was staged by computed tomography (CT), positron emission tomography (PET) using a modified dual-headed gamma camera, and mediastinoscopy. She then underwent three cycles of cisplatin-containing chemotherapy. After the chemotherapy, CT demonstrated a residual 10 mm mass in the right upper lobe and a considerable reduction in size of the mediastinal lymphadenopathy. Functional tumour imaging with PET showed no abnormality, suggesting that there was no remaining viable tumour. At right upper lobectomy a complete pathological response was confirmed. We discuss PET, the potential new applications of gamma camera technology, and the use of cisplatin-containing chemotherapy in non-small cell lung cancer.

Superior vena cava obstruction in prostate cancer.

This report describes the case history of a man with adenocarcinoma of the prostate. After an initial response to maximal androgen blockade, he developed massive mediastinal and cervical lymphadenopathy, causing left recurrent laryngeal nerve palsy and superior vena cava obstruction. Biopsy confirmed metastatic prostate cancer and he responded well to local radiotherapy. The hormonal treatment of advanced prostate cancer is discussed.

Aldose and aldehyde reductases: structure-function studies on the coenzyme and inhibitor-binding sites.

PURPOSE: To identify the structural features responsible for the differences in coenzyme and inhibitor specificities of aldose and aldehyde reductases. METHODS: The crystal structure of porcine aldehyde reductase in complex with NADPH and the aldose reductase inhibitor sorbinil was determined. The contribution of each amino acid lining the coenzyme-binding site to the binding of NADPH was calculated using the Discover package. In human aldose reductase, the role of the non-conserved Pro 216 (Ser in aldehyde reductase) in the binding of coenzyme was examined by site-directed mutagenesis. RESULTS: Sorbinil binds to the active site of aldehyde reductase and is hydrogen-bonded to Trp 22, Tyr 50, His 113, and the non-conserved Arg 312. Unlike tolrestat, the binding of sorbinil does not induce a change in the side chain conformation of Arg 312. Mutation of Pro 216 to Ser in aldose reductase makes the binding of coenzyme more similar to that of aldehyde reductase. CONCLUSIONS: The participation of non-conserved active site residues in the binding of inhibitors and the differences in the structural changes required for the binding to occur are responsible for the differences in the potency of inhibition of aldose and aldehyde reductases. We report that the non-conserved Pro 216 in aldose reductase contributes to the tight binding of NADPH.

Systemic metastases of glioblastoma multiforme.

The case history of a 40-year-old man who developed systemic metastases 2 years after treatment for glioblastoma is reported. The diagnosis was confirmed by biopsy. The role of immunohistochemistry in the diagnosis of this rare event is discussed and illustrated.

Effect of experimental diabetes mellitus on gentamicin-induced acute renal functional changes in the anaesthetized rat.

1. Rats with streptozotocin (STZ) diabetes are protected from gentamicin (GEN) nephrotoxicity. Because the chronic renal damage from GEN is preceded by acute renal functional changes (notably hypercalciuria), the present study aims to determine whether diabetes may also protect against the acute effects of the drug. If there is a link between the rapid physiological actions of GEN and its subsequent nephrotoxicity, the former may also be affected by the diabetic condition. 2. Standard renal clearance techniques were performed on anaesthetized rats that had been injected with STZ or vehicle 2 weeks previously. All animals were infused with 0.9% NaCl for 5 h and then either GEN (0.28 mg/kg per min) or 0.9% NaCl alone for 2 h. 3. Baseline fractional calcium excretion (FE(Ca)) of diabetic rats was three-fold that of control animals (6.6+/-0.2 vs 2.2+/-0.2%, respectively; P<0.01, MANOVA). Following GEN infusion, a comparable increase in FE(Ca) occurred in control and diabetic rats (5.3+/-0.6 vs 5.3+/-0.8%, respectively; NS). 4. Streptozotocin diabetes, therefore, does not alter the acute hypercalciuric response to GEN. This may suggest that the acute effects of GEN on renal calcium handling do not contribute to the subsequent nephrotoxicity. However, the higher baseline FE(Ca) seen in diabetic rats may afford protection against the renal injury caused by gentamicin.

Acute gentamicin-induced hypercalciuria and hypermagnesiuria in the rat: dose-response relationship and role of renal tubular injury.

1. Standard renal clearance techniques were used to assess the dose-response relationship between acute gentamicin infusion and the magnitude of hypercalciuria and hypermagnesiuria in the anaesthetized Sprague-Dawley rat. Also investigated were whether these effects occurred independently of renal tubular cell injury. 2. Acute gentamicin infusion was associated with a significant hypercalciuria and hypermagnesiuria evident within 30 min of drug infusion. The magnitude of these responses was related to the dose of drug infused (0.14-1.12 mg kg(-1) min[-1]). Increased urinary electrolyte losses resulted from a decreased tubular reabsorption of calcium and magnesium. 3. A rapid dose-related increase in urinary N-acetyl-beta-D-glucosaminidase (NAG) excretion was also observed in response to gentamicin infusion. However, there was no evidence of renal tubular cell injury and no myeloid bodies were observed within the lysosomes of the proximal tubular cells. Gentamicin may thus interfere with the mechanisms for cellular uptake and intracellular processing of NAG causing increased NAG release into the tubular lumen. 4. The absence of changes in renal cellular morphology indicates that the excessive renal losses of calcium and magnesium were an effect of gentamicin per se and not the result of underlying renal tubular injury. The renal effects described in this paper were apparent after administration of relatively low total drug doses, and with plasma concentrations calculated to be within the clinical range. These findings suggest that disturbances of plasma electrolyte homeostasis could occur in the absence of overt renal injury in patients receiving aminoglycoside antibiotics.

An ultrastructural histochemistry and light microscopy study of the early development of renal proximal tubular vacuolation after a single administration of the contrast enhancement medium "Iotrolan".

The time course of contrast media (CM)-induced renal proximal tubular vacuolation was investigated in rats by light microscopy, transmission electron microscopy (TEM), and ultrastructural histochemistry for acid phosphate activity. Young adult male rats were treated with a single dose of 3.0 g I/kg Iotrolan (Isovist 300 mg I/ml) and sacrificed at 0 min, 5-min, 15-min, 15-min, 2-hr, and 24-hr intervals. Light microscopy of vibratome sections of freshly excised tissue of cryostat and paraffin sections was also performed to allow comparison of the appearance of the vacuoles in the fresh state with light and electron microscopy. The sequence of events seen to occur can be summarized as follows. CM-induced vacuolation occurred at a low level a soon as 5 min after compound administration. The vacuolation was observed by TEM but could not be detected by light microscopy. This was followed by an increase in size and numbers of vacuoles up to the 24-hr timepoint with a sequential increase in the staining for acid phosphatase activity of the vacuoles, most marked at the 24-hr timepoint. At timepoints less than 24 hr there appeared to be no marked increased in the normal complement by lysosomes or in the components of the Golgi-endoplasmic reticulum-lysosome pathway. At 24 hr, the vast majority, but not all, of the CM-induced vacuoles were positive for acid phosphatase activity. The intensity of staining varied, and there was evidence of infusion of small lysosomes with CM-induced vacuoles. These results suggest that formation of CM-induced vacuoles is a 2-stage process, following a normal pathway for the handling of endogenous and exogenous substances.

Comparative hypolipidaemic and peroxisomal effects of ciprofibrate, clofibric acid, and their respective difluorocyclopropyl and 4-fluoro-substituted analogues in rat.

1. We investigated the biological activity of the difluoro analogue (WIN 36117) of ciprofibrate, a potent peroxisome proliferator, and re-examined the relative activity of clofibric acid and its 4-fluoro analogue (fluorofibric acid) in the rat. 2. Twenty-four hours after a single dose, ciprofibrate and WIN 36117 produced dosage-related reductions in plasma cholesterol (16-42 and 9-34% respectively) and triglycerides (14-32 and 9-22% respectively). However, a single dose of clofibric acid or fluorofibric acid produced hypocholesterolaemia only (32-58 and 9-29% reductions respectively). 3. After treatment for 7 days reductions in cholesterol were similar at all dosages of ciprofibrate (45% reduction, mean across groups) whereas the effects of WIN 36117, clofibric acid and fluorofibric acid were still dosage related (reductions of 21-44, 37-43 and 2-28% respectively). Hypotriglyceridaemia was produced by all compounds (ciprofibrate 36-50%, WIN 36117 14-36%, clofibric acid 18-48%, fluorofibric acid 6-28%). 4. After treatment for 14 days all compounds produced dosage-related decreases in plasma fibrinogen (ciprofibrate 18-33%, WIN 36117 7-11%, clofibric acid 13-26%, fluorofibric acid 7-15%). 5. Peroxisomal beta-oxidation activity was increased by WIN 36117 (4.8-fold) and fluorofibric acid (4.2-fold) although these increases were less than those produced by ciprofibrate (13.6-fold) and clofibric acid (7.0-fold). WIN 36117 and fluorofibric acid also produced smaller increases in peroxisome numbers, liver weight, and carnitine acetyl transferase activity and smaller decreases in glutathione S-transferase and glutathione peroxidase activities. 6. Maximal increases in peroxisomal beta-oxidation activity produced in cultured rat hepatocytes by WIN 36117 and fluorofibric acid were 58 and 72% of those produced by ciprofibrate and clofibric acid respectively. 7. These results indicate the difluoro and 4-fluoro analogues of ciprofibrate and clofibric acid are hypolipidaemic agents and peroxisome proliferators but with reduced potencies relative to the parent molecules.

Ketorolac for early postoperative analgesia.

STUDY OBJECTIVE: To determine the efficacy and speed of onset of analgesia of a single dose of intravenous (IV) or intramuscular (IM) ketorolac tromethamine following major orthopedic surgery. STUDY DESIGN: Double-blind, randomized, placebo-controlled trial. SETTING: A district general hospital in England. PATIENTS: 112 patients aged 18 to 80 years suffering moderate or severe pain following orthopedic surgery. INTERVENTIONS: Patients were randomized to receive 30 mg ketorolac IV, 30 mg ketorolac IM, or placebo following surgery. MEASUREMENTS AND MAIN RESULTS: Verbal pain intensity scores were performed prior to admission to the study, then frequently for the first 45 minutes following administration of study medication, and subsequently at hourly intervals. Times to request for further analgesia were noted. Patient assessment of overall acceptability and pain relief of the study medication was recorded. There was no statistical difference in speed of onset of analgesia between the ketorolac groups and placebo. Median (range) times to first analgesic following study drugs were: ketorolac IV 45 minutes (9 to 1440 minutes), ketorolac IM 34 minutes (10 to 1440 minutes), placebo 24 minutes (10 to 615 minutes). There was a statistically significant difference between the ketorolac groups and placebo (ketorolac IV vs. placebo, p < 0.01; ketorolac IM vs. placebo, p = 0.03). Patient assessment of overall acceptability and pain relief was significantly better for IV ketorolac compared with placebo (p < 0.01). By 6 hours, 78% of the IV ketorolac group and 95% of the IM ketorolac and placebo groups required further analgesia. CONCLUSIONS: Despite high patient acceptability compared with placebo, the use of ketorolac as the sole analgesic failed to control postoperative pain following major orthopedic surgery. IV administration of ketorolac conferred no advantages over the IM route with regard to efficacy or speed of onset.

Na,K-ATPase response to osmotic stress in primary dog lens epithelial cells.

PURPOSE: Na,K-ATPase activity increases in lens cells exposed to hypertonic stress. To test whether the increase in activity involves stimulation of Na,K-ATPase expression, dog lens epithelial cells were subjected to hypertonic stress, and the time course of Na,K-ATPase protein and mRNA response was measured. METHODS: Primary cultures of dog lens epithelial cells were maintained in isotonic or hypertonic media over the course of several days. Rubidium-86 uptake measurements, immunoreactive protein, and northern blot analysis were performed. RESULTS: Dog lens epithelial cells exposed to hypertonic stress from culture medium supplemented with 150 mM NaCl or 250 mM cellobiose showed a twofold increase in Na,K-ATPase activity. The increase in activity was blocked by cycloheximide and was reversible when the cells were returned to isotonic medium. This activity was unaffected by the aldose reductase inhibitor, tolrestat. Na,K-ATPase protein and mRNA levels increased in cells exposed to medium containing 150 mM NaCl. Northern blot analysis showed that the alpha-1 and beta-1 mRNA levels increased as early as 6 hours and maximally increased 1.5-fold to twofold by 12 to 24 hours. CONCLUSIONS: Elevation of Na,K-ATPase activity in dog lens epithelial cells exposed to hypertonic stress was associated with increased expression of Na,K-ATPase subunit mRNAs and was dependent on protein synthesis. These results suggest that upregulation of the enzyme activity is the result of an induction of Na,K-ATPase.

Residues affecting the catalysis and inhibition of rat lens aldose reductase.

Aldose reductase (AR), the first enzyme of the polyol pathway, has been implicated in diabetic complications. Results of recent clinical studies have shown that compounds that inhibit aldose reductase (ARIs) and block the flux of glucose through the polyol pathway have provided benefit to diabetic neuropathic patients. Since many ARIs show broad substrate specificity, emphasis on the structure-function properties of the AR enzyme will help in the refinement and design of future inhibitors. To this end, catalysis and inhibition of rat lens aldose reductase was examined following site-directed mutagenesis. Replacement of tyrosine 48 with phenylalanine (Y48F) resulted in an enzyme form with less than 0.25% activity with DL-glyceraldehyde and no detectable activity with p-nitrobenzaldehyde or xylose, although circular dichroism spectra and NADPH binding affinity were similar to wild-type AR. Mutation of histidine 110 to glutamine (H110Q) also resulted in a less active protein with an approximate 3-fold decrease in kcat for the reduction of DL-glyceraldehyde; slight or no activity was measured with other substrates and an increase of 195-fold over wild type was observed in the Km for glyceraldehyde. H110Q was less sensitive to inhibition by aldose reductase inhibitors. The most dramatic change was seen with imeristat, which showed an 1800-fold increase in IC50. Mutation of cysteine 298 to serine (C298S) affected enzyme function by increasing kcat 2- to 4-fold and increasing Km 15- to 48-fold, with DL-glyceraldehyde, p-nitrobenzaldehyde or xylose as substrates. As a result kcat/Km, catalytic efficiency, dropped to approx. 10% of control. Inhibition of C298S was not noticeably different from wild type. Substitution of histidine 187 or 200 with glutamine (H187Q, H200Q) had little effect on AR catalysis or inhibition. Based on structural and mutagenesis studies of human AR and the conservation of amino acids between human and rat, these data would indicate that Y48, H110, and C298 are important residues in the active site of rat AR and that Y48 is most likely the proton donor during substrate reduction by rat lens aldose reductase. In addition, these studies indicate that mutagenesis of H110 also affects aldose reductase inhibition.

Pyruvate dehydrogenase deficiency: molecular basis for intrafamilial heterogeneity.

Two half-brothers and their mother had symptomatic pyruvate dehydrogenase complex deficiency. The infants had severe congenital lactic acidosis, seizures, and apneic spells and died at the ages 3 and 4 months. The mother was less symptomatic with mental retardation, truncal ataxia, and dysarthria. The residual pyruvate dehydrogenase activities in cultured skin fibroblasts from the 2 infants and their mother were 7, 15, and 10% of control values. Immunoblot analysis showed negligible amounts of E1 alpha and E1 beta subunits of the complex. Northern blot analysis for the E1 alpha subunit showed normal results. In the 2 sons, complementary DNA sequence analysis revealed a cytosine to thymine mutation in exon 4, resulting in a change of arginine 127 to tryptophan in the E1 alpha subunit. Restriction enzyme analysis of the polymerase chain reaction product representing exon 4 of the E1 alpha gene revealed that the mother was a heterozygotes. Complementary DNA restriction analysis and methylation analysis of the X chromosome DXS255 loci revealed skewed activation of the mutant allele, consistent with the deficient pyruvate dehydrogenase activity in the mother's fibroblasts. The milder maternal phenotype is consistent with variable X-inactivation patterns in different organs of female heterozygotes.

Lack of peroxisome proliferation in marmoset liver following treatment with ciprofibrate for 3 years.

The effect of treatment of marmosets with ciprofibrate for 3 years on activities of hepatic enzymes, hepatic histomorphology, and ultrastructure were investigated. Male and female marmosets were dosed with ciprofibrate (2, 10, and 20 mg/kg) by oral gavage once daily for 3 years. No effect on liver weight (adjusted for body weight) or liver morphology was observed. The activities of catalase, glutathione peroxidase, alpha-glycerophosphate dehydrogenase, benzphetamine N-demethylase, and ethoxyresorufin O-deethylase were unaffected by treatment with ciprofibrate. Activity of glutathione transferase was increased in the low dosage group but unaffected in the mid and high dosage groups. Modest increases in activities of peroxisomal beta-oxidation (2.5-fold, maximal), carnitine acetyl transferase (1.7-fold, maximal), and carnitine palmitoyl transferase (2-fold, maximal) were observed. Cytochemical staining and quantitative image analysis failed to indicate any effect on peroxisomal number, size, or volume density. Similarly, there was no increase in lipofuscin deposition. This study provides data on the effects of a potent peroxisome proliferator on primate liver following a dosing period much greater than that used in previously published studies and is further evidence that the marmoset is relatively insensitive to the well-documented effects that ciprofibrate and other peroxisome proliferators have on rat liver.