Phase I/II study of adding intraperitoneal paclitaxel in patients with pancreatic cancer and peritoneal metastasis.

BACKGROUND: Intraperitoneal chemotherapy using paclitaxel is considered an experimental approach for treating peritoneal carcinomatosis. This study aimed to determine the recommended dose, and to evaluate the clinical efficacy and safety, of the combination of intravenous gemcitabine, intravenous nab-paclitaxel and intraperitoneal paclitaxel in patients with pancreatic cancer and peritoneal metastasis. METHODS: The frequencies of dose-limiting toxicities were evaluated, and the recommended dose was determined in phase I. The primary endpoint of the phase II analysis was overall survival rate at 1 year. Secondary endpoints were antitumour effects, symptom-relieving effects, safety and overall survival. RESULTS: The recommended doses of intravenous gemcitabine, intravenous nab-paclitaxel and intraperitoneal paclitaxel were 800, 75 and 20 mg/m2 respectively. Among 46 patients enrolled in phase II, the median time to treatment failure was 6·0 (range 0-22·6) months. The response and disease control rates were 21 of 43 and 41 of 43 respectively. Ascites disappeared in 12 of 30 patients, and cytology became negative in 18 of 46. The median survival time was 14·5 months, and the 1-year overall survival rate was 61 per cent. Conversion surgery was performed in eight of 46 patients, and those who underwent resection survived significantly longer than those who were not treated surgically (median survival not reached versus 12·4 months). Grade 3-4 haematological toxicities developed in 35 of 46 patients, whereas non-haematological adverse events occurred in seven patients. CONCLUSION: Adding intraperitoneal paclitaxel had clinical efficacy with acceptable tolerability.

ANTECEDENTES: La quimioterapia intraperitoneal con paclitaxel se considera una terapia experimental para el tratamiento de la carcinomatosis peritoneal. Este estudio tuvo como objetivo determinar la dosis recomendada y evaluar la eficacia clínica y la seguridad de la combinación de gemcitabina intravenosa, nab-paclitaxel intravenoso y paclitaxel intraperitoneal en pacientes con cáncer de páncreas y metástasis peritoneales. MÉTODOS: Se evaluaron las frecuencias de las toxicidades limitantes de la dosis, y la dosis recomendada se determinó en la fase I. El objetivo principal de la fase II fue la tasa de supervivencia global a 1 año. Los objetivos secundarios fueron los efectos antitumorales, los efectos de alivio de los síntomas, la seguridad y la supervivencia global. RESULTADOS: Las dosis recomendadas de gemcitabina intravenosa, nab-paclitaxel intravenoso y paclitaxel intraperitoneal fueron de 800, 75 y 20 mg/m2 , respectivamente. De los 46 pacientes incluidos en la fase II del estudio, la mediana de tiempo hasta el fracaso del tratamiento fue de 6,0 meses (rango, 0-22,6). Las tasas de respuesta y de control de la enfermedad fueron del 45% y 95%, respectivamente. La ascitis desapareció en el 40% de los pacientes, y la citología se negativizó en el 39% de los pacientes. La mediana del tiempo de supervivencia fue de 14,5 meses y la tasa de supervivencia global a 1 año del 60,9%. La cirugía de rescate se realizó en ocho (17%) pacientes, y los que se sometieron a cirugía sobrevivieron significativamente más tiempo que los que no fueron tratados quirúrgicamente (mediana de supervivencia no alcanzada versus 12,4 meses). Las toxicidades hematológicas de grado 3/4 ocurrieron en el 76% de los pacientes, mientras que los eventos adversos no hematológicos se presentaron en el 15% de los pacientes. CONCLUSIÓN: Agregar paclitaxel intraperitoneal tuvo eficacia clínica con una tolerabilidad aceptable. (UMIN000018878).

Effectiveness of Bortezomib in a Patient With Acute Rejection Associated With an Elevation of Donor-Specific HLA Antibodies After Small-Bowel Transplantation: Case Report.

BACKGROUND: A significant association between donor-specific antibody (DSA) and graft rejection has recently been documented. However, confirmed strategy has not been established for DSA-associated rejection after intestinal transplantation (ITx). CASE REPORT: A 20-year-old male patient with chronic intestinal obstruction caused by hypoganglionosis of the entire intestine underwent cadaveric donor ITx with grafting performed on 232 cm of the small intestine, cecum, and a part of the ascending colon. On post-operative day (POD) 14, a histological evaluation showed an acute rejection of indeterminate grade. The patient had severe acute rejection on POD 16, which prompted us to administer bolus steroids and polyclonal anti-thymocyte antibody, along with baseline maintenance immunosuppression. The histopathological findings of the graft indicated typical acute cellular rejection, although C4d was positive. We then detected donor-specific HLA antibody. The patient initially responded well to the therapy and showed decreased histological rejection signs. However, the refractory low-grade rejection persisted in the graft. During this period, the patient showed increased levels of DSA, and we speculated that the persistent rejection was associated with DSA; thus, bortezomib was administered at this stage as a salvage therapy. This rejection was thereafter successfully controlled without severe adverse effect. Twenty-three months after ITx, the patient is currently alive with complete enteral autonomy. CONCLUSIONS: A case of acute graft rejection followed by a marked elevation of DSA is presented. In this particular case, a modified treatment protocol using bortezomib in addition to the typical immunosuppressive agents was effective.

Advantages of oxygen inhalation therapy for postoperative pulmonary hypertension.

Total correction was performed in a case of complete transposition of the great arteries (TGA) with severe pulmonary vascular obstructive disease (PVOD). Although severe pulmonary hypertension remained after surgery, oxygenation was continued for 15 months, which included a shift to at-home oxygen inhalation therapy (HOT). Cardiac catheterization 15 months after surgery demonstrated that pulmonary hypertension was greatly improved. For patients in whom the palliative Mustard operation is considered due to severe PVOD on the basis of lung biopsy diagnosis, total correction of TGA is possible by employing HOT after surgery.

Selective attachment of pyrenyl groups to ethylene-co-vinyl acetate copolymers: dynamic and static fluorescence studies.

Micromorphology is an important factor in determining polymer properties and uses. Here, steady-state and dynamic fluorescence from covalently attached 1-alkylpyrenyl groups are used to investigate the micromorphology of several random ethylene-co-vinyl acetate (EVA) copolymers with defined compositions of vinyl acetate monomer. The results are compared with those from homopolymers of high- and low-density polyethylenes and poly(vinyl acetate). Selective attachment of pyren-1-yl groups to polymer chains was accomplished by irradiation of pyren-1-yldiazomethane sorbed into polymer films. Steady-state fluorescence spectra and fluorescence decay rates of attached pyrenyl groups in films of the polymers have been compared with those from films with sorbed pyrene. I1/I3 intensity ratios from vibrational bands in the fluorescence spectra and the fluorescence decay rates of attached 1-alkylpyrenyl groups are much less sensitive to changes in the copolymer composition than are those of pyrene. These observations suggest that attachment occurs selectively to the olefinic segments (rather than to the acetate-rich regions) of polymer chains of EVA copolymers. This conclusion is consistent with the known preferences for reaction by pyren-1-ylcarbene in solution.

Reduction in recalcitrant pulmonary hypertension after operation for atrial septal defect.

We present the case of a patient with atrial septal defect and severe pulmonary hypertension with pulmonary artery peak pressure greater than 110 mm Hg. Open lung biopsy was done prior to the corrective operation, and pathological findings in the small pulmonary arteries included "musculoelastosis" and complete occlusion of 70% of these small arteries and arterioles. The atrial septal defect was closed, and long-term oral prostacyclin therapy was initiated. Pulmonary artery peak pressure decreased to 65 mm Hg 2 years after the operation. This case demonstrates that in a patient with 70% complete occlusion of small pulmonary arteries and arterioles resulting from "musculoelastosis," not only is surgical intervention possible but also pulmonary artery pressure decreases in the long term after operation.

[Indication for lung biopsy and usefulness of lung biopsy].

The criteria of open lung biopsy for operative indication were determined on the basis of hemodynamics in each congenital cardiac anomalies with pulmonary hypertension. More than 10.6, 8 and 8 units. m2 of pulmonary vascular resistance (PVR) were considered as indication for open lung biopsy in the patients with complete transposition of the great arteries, complete atrioventricular canal defect and atrial septal defect respectively. Lung biopsy should be done in patients with ventricular septal defect when PVR is more than 8 units. m2 and if it is greater than 4 with the oxygen inhalation test or 6 with the Tolazoline test. The usefulness of lung biopsy was also emphasized on the basis of the postoperative result in which lung biopsy diagnosis has been done.

Purification and characterization of a NAD+-dependent sorbitol dehydrogenase from Japanese pear fruit.

NAD+-dependent sorbitol dehydrogenase NAD-SDH, EC 1.1.1.14) from Japanese pear fruit was purified to apparent homogeneity (single band by SDS-PAGE with silver staining), and had a specific activity of 916.7 nKatal/mg protein. The molecular of the native enzyme was calculated to be 160 kDa by gel filtration, whereas SDS-PAGE gave a subunit size of 40 kDa, indicating that the native enzyme is a homotetramer. The protein immunologically reacted with an antibody raised in rabbit against the fusion protein expressed in E. coli harboring an apple NAD-SDH cDNA. The Km, values for sorbitol and fructose were 96.4+/-8.60 and 4239+/-33.5 mM, respectively, and optimum pH for sorbitol oxidation was 9.0 and 7.0 for fructose reduction. Pear NAD-SDH had a very narrow substrate specificity, that is, sorbitol, L-iditol, xylitol and L-threitol were oxidized but not any of the other alcohols tested. These data suggest the structural importance of an S configuration at C-2 and an R configuration at C-4 in the substrate(s). Its enzymatic activity was strongly inhibited both by heavy metal ions such as mercury, and by thiol compounds, such as L-cysteine. However, the addition of zinc ion reversed the enzyme inactivation caused by addition of L-cysteine.

Purification and characterization of two sucrose synthase isoforms from Japanese pear fruit.

Two isoforms (SS I and SS II) of sucrose synthase (SS; EC 2.54.1.13) were purified from Japanese pear fruit and their properties were compared. SS I mainly appeared in young fruit and SS II mainly in mature fruit. SS I and SS II were purified to the specific activity of 3.37 and 4.26 (units (mg protein)(-1)), respectively. The MW of native and subunit proteins of SS I and SS II were almost the same and both SSs seemed to be a tetramer composed of an 83 kDa polypeptide. However, the ionic charges of the native proteins and the kinetic parameters of SSs were different. Specifically, the Km value for UDP-glucose in SS I was the same as that for UDP, while the Km value for UDP-glucose in SS II was less than that for UDP. SS II easily reacted for sucrose synthesis than sucrose cleavage compared with SS I. Therefore, it is considered that SS I and SS II play different roles in the utilization of carbohydrate in young and mature fruit, respectively.

Pulmonary vascular changes induced by congenital obstruction of pulmonary venous return.

BACKGROUND: Pulmonary venous obstruction (PVO) induces pulmonary arterial hypertension, as well as pulmonary venous hypertension, and jeopardizes the repair of cardiac lesions. METHODS: Four cases of congenital mitral stenosis and 4 cases of cor triatriatum (Lucas type A), ages ranging from 2 months to 16 years, were histologically examined on pulmonary vasculature. Histometrical analysis was performed on medial thickness and intimal changes of both pulmonary arteries and veins. For comparison, the examination of pulmonary vasculature in ventricular septal defect (VSD) cases was also performed. RESULTS: Medial thickening and intimal fibrosis, in both pulmonary arteries and veins with widespread lymphangiectasia, were characteristic vascular changes of PVO cases. Medial thickness of pulmonary arteries was correlated with preoperative pulmonary arterial pressure (PAP) (r = 0.77, p = 0.03 for systolic PAP), and greater than that of VSD cases. Medial thickness of pulmonary veins was also greater in PVO cases. Intimal fibrosis of pulmonary arteries and veins was seen extensively at the advanced ages, whereas no plexiform lesions or more advanced stages of pulmonary vascular disease were present. CONCLUSIONS: Congenital PVO induced progressive medial thickening and intimal fibrosis in pulmonary arteries and veins accompanied by lymphangiectasia. However, no plexiform lesions or more advanced stages of pulmonary vascular disease were present, which may explain the reversibility of pulmonary hypertension due to congenital PVO.

Extremely thickened media of small pulmonary arteries in fatal pulmonary hypertension with congenital heart disease--a morphometric and clinicopathological study.

There are patients with congenital heart disease and fatal pulmonary hypertension in whom the medial hypertrophy of the small pulmonary arteries is quite beyond the extent of ordinary cases of hypertension, a condition described as pulmonary hypertension with extremely thickened media of small pulmonary arteries (PH/ETM). Lungs from 6 infants, all younger than 2 years of age, who had congenital heart disease and fatal pulmonary hypertension, were analyzed by accurately measuring the media using Suwa's method. In PH/ETM, the media of the small pulmonary arteries was shown to be not only unusually thick, but extending toward the periphery, whereas the intimal changes were unexpectedly mild. In the PH/ETM group, the % wall thickness at a diameter of 50 microm (%Tw(50)), determined from regression analysis, was 23.2+/-1.3%, which was significantly higher than in either the control (10.3+/-1.2%) or ventricular septal defect group (18.9+/-1.6%). In persistent pulmonary hypertension of the newborn (PPHN), it was 22.3+/-1.8%, not significantly different from PH/ETM. The striking medial hypertrophy in PH/ETM and PPHN was apparently confined to small pulmonary arteries and in both conditions is likely to be the result of maldevelopment of these arteries. Surgical intervention may trigger a critical elevation of the pulmonary arterial resistance.

Structural relationship of kappa-type light chains with AL amyloidosis: multiple deletions found in a VkappaIV protein.

Two amyloidogenic Bence Jones proteins (Am37 VkappaIV and NIG1 VkappaI) and one non-amyloidogenic protein (NIG26 VkappaIII) were characterized. The protein Am37 had four deletions when compared with the translated germ-line gene sequence: two Ser residues following position 27 (27e, 27f) in CDR1 and two amino acids Pro-44, and Tyr-49 in FR2 were deleted. A strictly conserved salt-bridge-forming amino acid, Asp-82, was replaced by the hydrophobic residue Leu. In a comparative study of amyloidogenic and non-amyloidogenic proteins, five amino acids (Ser-10, Ala-13, Ser-65, Gln-90, and Ile-106) were found to be unique to NIG1 and several other amyloidogenic proteins. Additional substitutions also occur within these proteins. These substitutions might be significant in altering protein folding as well as in contributing to their aggregation as amyloid fibrils.

Molecular cloning of vacuolar H(+)-pyrophosphatase and its expression during the development of pear fruit.

The cDNA of vacuolar proton-translocating inorganic pyrophosphatase was cloned from pear fruit. It contained an open reading frame of 2,301 nucleotides, coding for a polypeptide of 767 amino acids. The level of mRNA was very low in young fruit and increased with maturation, differing from the changes in the level of polypeptide.

Progressive pulmonary vascular disease after pulmonary artery banding and total correction in a case of ventricular septal defect and pulmonary hypertension.

A 7-month-old infant with ventricular septal defect and pulmonary hypertension underwent pulmonary artery banding, which resulted in a decrease in the pulmonary arterial peak pressure from 102 to 54 mmHg. Lung biopsy findings showed at most an early grade 3 Heath-Edwards classification, and an index of pulmonary vascular disease of 1.4, both of which indicated operability for total correction. Small pulmonary arteries less than 100 microns in diameter, however, showed marked hydropic changes in the medial smooth muscle cells. Total correction was performed at the age of 2 years, but the pulmonary arterial pressure failed to decrease. A lung biopsy taken just after the closure of the ventricular septal defect contraindicated operability due to progressive pulmonary vascular disease at a grade 6 Heath-Edwards classification and an index of pulmonary vascular disease of 2.4. The patient died at 8 months after the operation, and an autopsy revealed still more advanced pulmonary vascular disease at a grade 6 Heath-Edwards classification and an index of pulmonary vascular disease of 2.8. The pathogenesis of arterial changes is discussed.

Identification and cDNA cloning of a protein abundantly expressed during apple fruit development.

A 60 kDa protein (MF-60) abundantly appearing in matured apple fruit was detected by SDS-PAGE of the soluble protein. It was partially purified through Butyl-Toyopearl and DEAE-cellulose. Its partial amino acid sequences were determined to isolate a full-length cDNA. MF-60 cDNA (mf-60) consisting of 1,825 bp containing an open reading frame of 1,524 bp and encoding a 54.2 kDa polypeptide. The deduced polypeptide of mf-60 has 81.1% identity to turgor-responsive protein 26 g from wilted garden pea shoot. Northern blot and Western blot analyses showed that the levels of the protein and the transcript of MF-60 changed in parallel through the developmental season; they were very low in young fruit at 36 DAF and 60 DAF, started to increase at 85 DAF, and then remained at a higher level from 114 DAF to 176 DAF. These results suggested that MF-60 functions are connected with fruit development but not with the fruit ripening induced by ethylene.

Structural relationship of lambda-type light chains with AL amyloidosis.

Three human amyloidogenic Bence Jones proteins, NIG76 VlambdaII, NIG204 VlambdaI, and NIG250 VlambdaV, were characterized. In a comparative study, three amino acids, Ser-25a, Thr-68, and Val-95, were found to be common to amyloidogenic proteins of the VlambdaII subgroup. NIG204 had an insertion of Pro residue following position 30 (30a). Proteins having an insertion at this position are invariantly amyloidogenic. NIG250 had a characteristic VlambdaV VL domain, with Mcg+ and KERN+ CL domain isotypes. Following the protein DEL, this is the second example of this subgroup. No common residue is found in the other subgroup proteins but unique substitutions do occur. It would seem that any substitution that causes an alteration in the protein conformation may lead to its being more prone to association with the amyloid processes.

Vacuolar H(+)-pyrophosphatase purified from pear fruit.

A vacuolar H(+)-translocating inorganic pyrophosphatase was purified from pear fruit through selective detergent treatments, Superose 6 and Mono Q column chromatography. The specific activity of the purified enzyme was 850 mumol h-1 mg protein-1. The Mr of V-PPase was 66 kDa by SDS-PAGE and the polypeptide cross-reacted with the antiserum against V-PPase of mung bean. The purified V-PPase was stimulated by potassium and inhibited by calcium and N, N'-dicyclohexylcarbodiimide.

[Repair of complete atrioventricular septal defect with severe pulmonary hypertension--effect of re-pulmonary artery banding and analysis of lung biopsy: a case report].

We report a case complete atrioventricular defect with severe pulmonary hypertension. The patient was a girl aged 2 years and 6 months with Down's syndrome who had undergone pulmonary artery banding (PAB) 2 years previously. Postoperative catheterization after PAB showed severe pulmonary hypertension. Pulmonary resistance values were 9.3 and 7.3 units at 1 year and 5 months and 1 year and 9 months respectively. We performed re-PAB and lung biopsy when the patient was 2 years and 6 months old. The biopsy specimen at re-PAB classified as Heath-Edwards grade 3 and had an IPVD score of 1.7, indicating tolerance to radical operation. Six months after re-PAB, pulmonary vascular resistance decreased a level at which radical operation could be performed safely. Radical operation was performed 1 year and 4 months after re-PAB. The post operative course was uneventful, and pulmonary hypertensive crisis did not occur. The lung biopsy at the final operation was classified as Heath-Edwards grade 3, had an IPVD score of 1.1, and showed improvement when compared with the pathological findings at re-PAB.

The histology of the lung in neonates with tricuspid valve disease and gross cardiomegaly due to severe regurgitation.

Lung autopsies from four neonates with Ebstein's anomaly or tricuspid valve dysplasia and gross cardiomegaly were examined. The mean cardiothoracic ratio was 92 +/- 0.5%. The degrees of pulmonary hypoplasia and pulmonary artery muscularization were assessed and were compared with those in lungs from four controls and four patients with diaphragmatic hernias. Lung and body weight ratios and radial alveolar counts, which reflect pulmonary hypoplasia and immaturity, were significantly decreased only in patients with diaphragmatic hernia. The thickness of the medical muscle layer in small pulmonary arteries was greater in patients with diaphragmatic hernia; however, in patients with tricuspid valve disease, it was relatively small. Abnormal vascular muscle extension was seen only in patients with diaphragmatic hernia. In the cases of tricuspid valve disease, although cardiomegaly and lung compression were severe, lung hypoplasia and immaturity were not, and neither abnormal medial thickening nor extension were found. Our results suggest that, at least in full-term infants with tricuspid valve disease, surgical relief of lung compression may improve respiratory function, even if the cardiomegaly is severe.

Surgical indication for congenital heart disease with extremely thickened media of small pulmonary arteries.

BACKGROUND: Nineteen patients (mean age, 7.6 months) with a percent wall thickness of more than 33% in the small pulmonary arteries were found to have extremely thickened media. Based on our findings, a criterion of operative indication is proposed. METHODS: The percentage of extremely thickened media of small pulmonary arteries for all pulmonary arteries was determined on microscopic lung sections and was introduced as an index for operative indication. RESULTS: Operative repair was performed in 16 patients: 9 died intraoperatively and 7 survived more than 12 months. In 4 of 5 patients that had pulmonary artery banding, medial hypertrophy remained despite pulmonary artery banding. Operative repair also had no positive effect. In operative and late deaths and in survivors without a decrease of pulmonary arterial pressure, the percentage of extremely thickened media of small pulmonary arteries was shown to be more than 10%, whereas in 5 survivors and 1 operative death with a significant postoperative decrease of pulmonary arterial pressure, the value was less than 7%. CONCLUSIONS: If a patient has less than 7% of small pulmonary arteries with extremely thickened media, operative repair is likely to be effective. When the value is higher than 10%, not only operative repair but also pulmonary artery banding cannot be recommended because of ineffectiveness and hazard.

Inoperable pulmonary vascular disease in infants with congenital heart disease.

BACKGROUND: Among 120 infants less than 12 months of age who had lung biopsy and autopsy, 20 were inoperable because of severe irreversible pulmonary vascular disease. METHODS: The infants were classified into three groups. Group 1 comprised 6 patients who showed complete obstruction of the small pulmonary arterial lumen and atrophy of the peripheral arterial media and who were considered to have absolute operative contraindications. Group 2 comprised 6 patients who had no pathologic findings of absolute operative contraindication and had an index of pulmonary vascular disease of more than 2.2. They were isolated as having advanced plexogenic pulmonary arteriopathy. Group 3 comprised 8 patients who had extremely thickened media of small pulmonary arteries, with abnormally thickened media extending into the small peripheral arteries characterized by extremely narrow lumina and medial thickness exceeding luminal diameter. RESULTS: Six of the 9 patients in whom operative repair was abandoned on the basis of preoperative or intraoperative lung biopsy are still alive. Of the 11 patients who underwent operation without biopsy, none survived. CONCLUSIONS: Preoperative or intraoperative lung biopsy and assessment of arteriopathy based on the above criteria are recommended in all patients in whom fatal pulmonary vascular disease is suspected.