A prospective phase II study of combined androgen blockade in patients with androgen receptor-positive metastatic or locally advanced unresectable salivary gland carcinoma.

Background: There is no standard first-line chemotherapy for recurrent/metastatic (RM) or unresectable locally advanced (LA) salivary gland carcinoma (SGC). Patients and methods: We conducted a single institution, open-label, single arm, phase II trial of combined androgen blockade (CAB) for androgen receptor (AR)-positive SGC. Leuprorelin acetate was administered subcutaneously at a dose of 3.75 mg every 4 weeks. Bicalutamide was administered orally at a daily dose of 80 mg. Patients were treated until progressive disease or unacceptable toxicities. Results: Thirty-six eligible patients were enrolled. Thirty-three patients had RM disease and three patients had LA disease. The pathological diagnoses were salivary duct carcinoma (34 patients, 94%) and adenocarcinoma, NOS (two patients, 6%). The best overall response rate was 41.7% [n = 15, 95% confidence interval (CI), 25.5%-59.2%], the clinical benefit rate was 75.0% (n = 27, 95% CI, 57.8%-87.9%). The median progression-free survival was 8.8 months (95% CI, 6.3-12.3 months) and the median overall survival was 30.5 months (95% CI, 16.8 months to not reached). Additional analyses between treatment outcomes and clinicopathological factors or biomarkers including AR positivity, human epidermal growth factor receptor 2 status, and its complex downstream signaling pathway gene mutations showed no statistically significant differences. Elevated grade 3 liver transaminases and increased serum creatinine were reported in two patients, respectively. Discontinuation of leuprorelin acetate or bicalutamide due to adverse event occurred in one patient. Conclusion: This study suggests that CAB has equivalent efficacy and less toxicity for patients with AR-positive RM or unresectable LA SGC compared with conventional chemotherapy, which warrants further study. Clinical Trial Registration: UMIN-CTR (http://www.umin.ac.jp/ctr/index-j.htm), identification number: UMIN000005703.

Expression and localization of ATP binding cassette (ABC) family of drug transporters in gastric hepatoid adenocarcinomas.

AIMS: Hepatoid adenocarcinomas are clinically chemoresistant; however, data concerning the mechanisms of chemoresistance are lacking. ATP-binding cassette (ABC) transporters play a role in the ATP-dependent outward efflux of drugs, and their function renders tumour cells multidrug resistant. We assumed that the expression of ABC transporters may be accompanied by hepatic differentiation because most ABC transporters are dominantly expressed in hepatocytes. The aim of this study was to investigate the expression of ABC transporters in hepatoid adenocarcinomas. METHODS AND RESULTS: The expression of P-glycoprotein, multidrug resistant-associated protein (MRP) 1, MRP2, MRP3 and MRP6 was investigated using immunohistochemistry in 13 cases of gastric hepatoid adenocarcinoma and 32 cases of control adenocarcinoma. P-glycoprotein was expressed in all cases examined. The positive rates of MRP1 (84.6% versus 21.9%), MRP2 (100% versus 43.8%) and MRP6 (61.5% versus 15.6%) were significantly higher in hepatoid than in control adenocarcinoma. MRP3 was negative in all hepatoid adenocarcinomas. Immunohistochemistry by polyclonal anti-carcinoembryonic antigen antibody, which detects bile canaliculi, suggested that MRP2 and MRP6 are located on bile canalicular-like structures in sheet or trabecular nests. CONCLUSIONS: These results support the hypothesis that ABC transporters participate in the mechanisms of multidrug resistance in hepatoid adenocarcinomas.

[Pacemaker implantation in a patient with sick sinus syndrome, complicated with persistent left superior vena cava and absent right superior vena cava; report of a case].

A 78-year-old man was referred to our hospital with syncope and palpitation. A Holter electrocardiography (ECG) revealed sick sinus syndrome (SSS), and an enhanced chest computed tomography (CT) scan showed persistent left superior vena cava (PLSVC) and absent right superior vena cava. Myocardial leads and a pacemaker implantation were peformed through left anterior thoracotomy approach. There were only 10 reports of pacemaker implantation in a patient with SSS complicated with PLSVC and absent right superior vena cava in Japan. Open thoracotomy approach was thought to be usuful for these patients.

Metastasis in para-aortic lymph nodes in patients with advanced gastric cancer, treated with extended lymphadenectomy.

BACKGROUND/AIMS: Lymph node dissection is an essential component of curative resection for advanced gastric cancer. To improve the survival of N2 patients, Asian surgeons have been performing D2+para-aortic lymph node dissection. The current study presents the results of lymph node status from multicenter trial of D2 and D2 + para-aortic nodal (No.16) dissection (D4 dissection). METHODOLOGY: Patients enrolled in the study had potentially curable gastric adenocarcinoma in an advanced stage, T2, T3 or T4/N1 or N2. Patients were randomized to undergo either D2 or D4 gastrectomy. RESULTS: Two hundred and seventy patients were registered and 136 and 134 patients were allocated into the D2 or D4 group, respectively. The average nodal yield of No.16 in D4 group was 18.4 +/- 14.1, ranging from 2 to 84. No.16 metastasis was detected in 12 (9.0%) of 134 D4 patients. One, 9 and 2 patients had simultaneous involvement in N1, N2, and N3 (No.8p, 12, 13 or 14). Namely, in 39 patients who were diagnosed as N2 from the lymph node status in N1 and N2 levels, nine (23.0%) patients had No.16 metastasis. The stage migration by D4 was found in 10 (7.5%). Logistic regression analysis revealed that the stations of No.7 and No.8 were the significant predictors of No.16 involvement. CONCLUSIONS: The present study may strongly suggest that prophylactic D4 dissection may be indicated for patients with N2 involvement, and that No.7 and No.8 are the junctional nodes for D4 dissection.

Operative morbidity and mortality after D2 and D4 extended dissection for advanced gastric cancer: a prospective randomized trial conducted by Asian surgeons.

BACKGROUND/AIMS: A randomized study was performed to evaluate morbidity and mortality after D2 (level 1 and 2 lymphadenectomy) and D4 (D2 plus lymphadenectomy of para-aortic lymph nodes) dissection for advanced gastric cancer. METHODOLOGY: Two hundred and fifty-six patients with advanced gastric adenocarcinoma were enrolled (128 to each group). Patients were randomly allocated into D2 (N = 128) or D4 (N = 128) group. The first and second tiers of lymph nodes are removed in D2 dissection. In D4 gastrectomy, the paraaortic lymph nodes were additionally removed. RESULTS: There was no indication of significant distribution bias with regard to age, sex, T-grade, and N-grade between the two groups. Operation time of D4 gastrectomy (369 +/- 120 min) was significantly longer than that of D2 gastrectomy (273 +/- 1103 min), and blood loss of the D4 group (872 +/- 683 mL) was significantly greater than that of the D2 group 571 +/- 527 mL (P < 0.001). Five (4%) and two (2%) medical complications developed in the D2 and D4 groups, respectively. Surgical complications developed in 28 (22%) and 48 patients (38%) after D2 and D4 gastrectomy. The most common complications were anastomotic leakage, pancreatic fistula, and abdominal abscess. Pancreatic fistula developed in 6 (19%) of 32 patients after D4 plus pancreatosplenectomy, but the incidence of pancreatic fistula after D2 gastrectomy plus pancreatosplenectomy was low (6%, 1/16). Two patients died within 30 days of operation (0.8%, 2/256), and each patient belonged to the D2 and D4 group. CONCLUSIONS: Although there is a significantly higher surgical complication rate in D4 dissection, D4 dissection can be done safely as D2 dissection when performed by well-trained surgeons.

Intra-arterial chemoradiation therapy with weekly low-dose cisplatin for squamous cell carcinoma of the maxillary sinus.

A new intra-arterial chemoradiation regimen that involves infusing low-dose cisplatin in combination with definitive irradiation was used in 36 patients diagnosed with squamous cell carcinoma of the maxillary sinus. The safety and therapeutic efficacy of this regimen were reviewed retrospectively. An intra-arterial catheter was inserted in a retrograde manner into the target artery via the superficial temporal artery or occipital artery. Intra-arterial infusion was performed using cisplatin at a dose of 20-50mg/m(2) per week for 6-8 weeks. At the same time, sodium thiosulphate was infused as a neutralizing agent. Irradiation was performed at 60Gy in 30 fractions. All 36 patients completed treatment. Grade 3 adverse events occurred in only seven patients (19.4%) and no grade 4 events were noted. As a primary therapy, the complete response rate was 83.3%, the partial response rate was 16.7%, and the overall response rate was 100%. The 2-year local control rate was 63.0%, and the 2-year overall survival rate was 75.5%. The 2-year preservation rate of the hard palate was 97.1%, that of the eyeball was 97.2%, and that of visual function was 94.4%. This treatment regimen can contribute to improving the quality of life of patients without reducing the curability of the therapy.

Synthesis of thromboxane receptor antagonists with bicyclo[3.1.0]hexane ring systems.

Thromboxane A2 receptor antagonists 11a, 15a, 26a, 30a, 34a, 36a, 46a, 52a, 61a, 72a, and 82a, which contain 6-oxabicyclo[3.1.0]hexane, 6-thiabicyclo[3.1.0]hexane, bicyclo[3.1.0]hexane, or 6,6-dimethylbicyclo[3.1.0]hexane ring systems with heptenoic and (phenylsulfonyl)amino side chains, and their corresponding sodium salts and methyl esters were synthesized. This study then examined the inhibitory effects of their sodium salts for the platelet aggregation induced by arachidonic acid with rabbit platelet-rich plasma and platelet aggregation induced by collagen with rat washed platelets.

Aldosterone antagonists. 1. Synthesis and biological activities of 11 beta,18-epoxypregnane derivatives.

Several steroid derivatives having the 11 beta,18-epoxypregnane skeleton, 7, 8, 19, 20, 21, and 31, were synthesized to evaluate their antialdosterone activity. Among them, 3-(9 alpha-fluoro-17 beta-hydroxy-3-oxoandrost-4-en-17 alpha-yl)propionic acid gamma-lactone (31) possessed fairly strong binding affinity for the cytoplasmic mineralocorticoid receptor of rat kidney and exhibited good aldosterone antagonist activity in an in vivo assay. However, its agonistic nature cannot be ignored. The properties of 31 as an aldosterone antagonist were enhanced by its very low to negligible binding affinity for the androgen, progestin, estrogen, and glucocorticoid receptors.

Aldosterone antagonists. 2. Synthesis and biological activities of 11,12-dehydropregnane derivatives.

Several steroid derivatives having the delta 11-pregnane skeleton with a 17-gamma-spirolactone function were synthesized to evaluate their antialdosterone activity and to elucidate the relation between their binding affinity to mineralocorticoid receptor (MR) and their mineralo- and/or antimineralocorticoid activity. Although many of the synthesized compounds showed strong binding affinity for the MR and aldosterone agonist activity, 3-(17 beta-hydroxy-3-oxoandrosta-1,4,6,11-tetraen-17 alpha-yl)propionic acid gamma-lactone exhibited good aldosterone antagonist activity in an in vivo assay. Its in vivo antiandrogenic activity was also found to be relatively weak.

The effect of anemia on skin blood flow in human.

The skin blood flow in the deltoid region was measured in 78 males by the Xenon 133 clearance method. A correlation was then made between age, hematocrit value, hemoglobin value and total protein determined at the time of skin blood flow measurement. From the data obtained, the following conclusions could be drawn: (1) skin blood flow significantly decreased with increasing age and with decreasing hematocrit and hemoglobin values; (2) skin blood flow showed the closest correlation with age (P < 0.001) and a weaker correlation (P < 0.01) with hematocrit and hemoglobin; (3) total protein demonstrated a significant decrease (P < 0.01) with a decrease in hematocrit and hemoglobin values giving rise to hypoproteinemia.

Surgical treatment of congenital dilatation of bile duct (choledochal cyst) with technical considerations.

Since the concept of an anomalous junction of the pancreaticobiliary ductal system was introduced, there has been rapid progress in the study of the pathophysiology and the surgical treatment of choledochal cyst, or congenital dilatation of the bile duct. Because of its various disadvantages, cystoenterostomy as a routine procedure for treatment of this condition has been superseded by hepaticoenterostomy after removal of the devastated bile ducts with blocking of communication with the pancreatic ducts. This article describes the technical details of the surgical correction of choledochal cyst.

The importance of the plasma amino acid molar ratio in patients with biliary atresia.

BACKGROUND: Plasma amino acid patterns and the therapeutic benefits of amino acid supplements are not examined well in postoperative patients with biliary atresia (BA). This study aimed to investigate profiles of the amino acid molar ratio, the Fischer molar ratio (FR, valine + leucine + isoleucine/phenylalanine + tyrosine), and relationships with other nutritional parameters and to assess the efficacy of enteral nutrient preparations for hepatic failure in patients with BA. METHODS: In study 1 profiles of FR were analyzed in 24 patients with BA (aged 3 to 12 years) in the postoperative period and compared with liver function tests and anthropometric measures. In study 2 10 patients with BA with a FR < 2.0 were begun on a dietary regimen consisting of an ordinary diet supplemented with a branched-chain amino acid-enriched elemental diet. RESULTS: Study 1: In jaundiced patients with total bilirubin levels > 2.0 mg/dL the FR remained below 2.0 throughout the period of observation, in contrast with nonjaundiced patients. The FR was closely related to the levels of serum albumin and plasma rapid turnover proteins and anthropometric measures as well as biochemical data reflecting intrinsic liver function. Study 2: A significant increase in rapid turnover proteins and improvement of general status were noted concurrently with an increase of the FR. CONCLUSIONS: The FR indicates a combination of nutritional status and intrinsic liver function in post-operative BA patients. The FR is a useful parameter in conducting nutritive therapy with a branched-chain amino acid-enriched elemental diet in those patients.

Common channel syndrome--diagnosis with endoscopic retrograde cholangiopancreatography and surgical management.

Six patients with intermittent bouts of vomiting, fever, abdominal pain, and jaundice beginning in infancy or early childhood were all demonstrated by endoscopic retrograde cholangiopancreatography to have an anomalous junction of the pancreaticobiliary ductal system with the formation of a characteristic long common channel. A varying degree of dilatation of the bile duct also was noted. Resection of choledochus followed by hepaticoduodenostomy was performed with satisfactory results invariably in all cases. The existence of a pathologic entity that might reasonably be designated "common channel syndrome" is discussed with some comments on its relationship with dilatation of the bile duct (choledochal cyst) as well as on the recommendable method of surgical treatment.

Beneficial effects of growth hormone combined with parenteral nutrition in the management of inflammatory bowel disease: an experimental study.

BACKGROUND: Growth hormone (GH) improves net protein anabolism and stimulates wound healing. Although GH is also known to exert the trophic effect on the intestinal tract, its role in the healing of intestinal ulceration is not known. The aim of this study was to evaluate the effects of exogenous GH coinfused with parenteral nutrition (PN) in an experimental model of inflammatory bowel disease in rats. METHODS: All rats underwent central venous cannulation and were randomized to two groups after induction of small intestinal ulceration with indomethacin. Both groups received the same PN formula. In addition, the GH group (n = 10) received subcutaneous injections of human GH at a dose of 1.0 IU/kg daily for 4 days, whereas the control group (n = 10) received injections of normal saline solution. Nitrogen balance, macroscopic inflammation score, intestinal myeloperoxidase activity, DNA content, and mucosal permeability were determined for each rat. Insulin-like growth factor-I (IGF-I) mRNA was detected by reverse transcription and polymerase chain reaction. RESULTS: Administration of GH significantly improved the cumulative nitrogen balance, ameliorated the gross inflammation score, and decreased intestinal myeloperoxidase activity. Similarly, intestinal permeability was significantly decreased in the GH group as compared with the control group. GH treatment resulted in increased plasma concentration of IGF-I and IGF-I mRNA expressions in both the liver and the small intestine compared with those in the control group. CONCLUSIONS: Exogenous GH plays an important role in accelerating intestinal healing in an experimental model of small bowel ulceration in rats. The mechanisms may include the stimulated IGF-I production, which thereafter augments intestinal epithelial cell growth.

Hydramnios associated with congenital mesoblastic nephroma: case report.

A case is reported of hydramnios due to excessive fetal urine production associated with congenital mesoblastic nephroma. Rapid growth of a right renal tumor and excessive fetal urine production were detected by measuring the size of the tumor and hourly fetal urine production during the development of hydramnios between 28-34 weeks of gestation. A female infant weighing 2200 g was born at 34 weeks' gestation. She lost 18% of her birth weight in the first 48 hours because of neonatal polyuria. Right nephrectomy and ureterectomy were performed 2 days after birth. After the operation, the neonatal polyuria improved dramatically. The right renal tumor was identified histologically as a mesoblastic nephroma. The importance is stressed of early and correct antenatal diagnosis of a renal tumor and precise estimation of urine production for postnatal management of hemodynamic change in cases of mesoblastic nephroma.

The effect of phlebotomy on serum erythropoietin levels in normal healthy subjects.

We evaluated endogenous serum erythropoietin (Epo) levels in 14 normal subjects (eight males and six females) after a single 400-ml phlebotomy. The subjects were followed up for 56 days. The hemoglobin (Hb) values of both males and females decreased to a nadir on days 3 to 7 post-phlebotomy. Hb values gradually increased, but did not completely recover to pre-phlebotomy levels by day 56. Serum Epo levels increased after 6 h post-phlebotomy, to 20.1 +/- 5.4 (mU/ml) in males and 20.7 +/- 7.0 in females, from the pre-phlebotomy levels of 14.6 +/- 4.0 in males and 13.4 +/- 4.1 in females, respectively. Epo levels continued to increase to peak levels of 25.5 +/- 6.3 in males and 28.7 +/- 11.5 in females on days 7 to 14 and thereafter decreased until day 56. Thus, the Epo response to a 400-ml phlebotomy was relatively small in magnitude and was not sufficient to initiate a significant increase in erythropoiesis. This finding suggests that the administration of recombinant human erythropoietin (rHu-Epo) may be effective for the prompt correction of anemia induced by autologous blood donation and for increasing the volume of predonated autologous blood.

Simple method for determining proper length of artificial chordae in mitral valve repair.

A simple method for determining the length of artificial chordae in mitral reconstructive operations is described. A small tourniquet is used for fine adjustment of the length of polytetrafluoroethylene stitches before tying them during leaking test. We have used this technique in 10 consecutive patients with anterior mitral leaflet prolapse since August 1992. Intraoperative transesophageal echocardiography revealed no or only trace mitral regurgitation after valve repair in all cases. This method minimized the time of determining the proper length of artificial chordae and achieved good results.

Right-sided partial sternotomy for minimally invasive valve operation: "open door method".

A simple technique for minimally invasive valve operations is described. With a 10-cm midline skin incision, excellent exposure of both the mitral and aortic valves is achieved through a right-sided partial sternotomy, which enables us to perform easy repair or replacement of these valves.

Vasorelaxant effect of a phosphodiesterase 3 inhibitor, olprinone, on isolated human radial artery.

The radial artery is currently used as a viable arterial conduit for myocardial revascularization. The aims of this study were to identify phosphodiesterase 3 isoenzyme in the human radial artery isolated for coronary artery bypass grafting, and to examine the vasorelaxant effect of a cardiotonic and vasodilating phosphodiesterase 3 inhibitor, 1, 2-dihydro-6-methyl-2-oxo-5-(imidazo[1,2-a]pyridin-6-yl)-3-pyridine carbonitrile hydrochloride monohydrate (olprinone). The phosphodiesterase 3 isoenzyme was separated from the radial artery by DEAE-Sepharose chromatography. Olprinone inhibited the phosphodiesterase 3 activity with an IC(50) value of 1.25 microM. Olprinone relaxed the phenylephrine-induced contractions of endothelium-denuded arterial strips with an EC(50) value of 0. 107+/-0.029 microM (n=5). These findings indicate that the human radial artery possesses phosphodiesterase 3 isoenzyme activity and olprinone causes potent relaxation of the arterial strip in vitro through inhibition of phosphodiesterase 3 isozyme activity.

Changes of the auditory system after cerebellopontine angle manipulations.

The current tendency in acoustic neuroma surgery to attempt the preservation of hearing function and the problem of accidental hearing loss caused by microsurgical neurovascular decompression operations for hemifacial spasm or trigeminal neuralgia prompted us to study the exact surgical vulnerability of the auditory system. The surgical procedures for operation on the cerebellopontine angle of dogs were carried out according to the sequence of the posterior fossa transmeatal operation for acoustic neuroma. The operation was tentatively divided into three stages: (a) craniectomy and dural opening, (b) cerebellar retraction, and (c) identification of the cochlear nerve in the unroofed internal auditory canal (IAC). The postoperative behavior of the auditory system was evaluated electrocochleographically (EcochG) and histologically. Overzealous retraction of the cerebellar hemisphere caused transient disturbance of the EcochG pattern. Mechanical stretching of both the cochlear nerve and the internal auditory artery may cause a disturbance in the synchronized discharge of the cochlear neurons. Various manipulations at the porus acusticus internus or the IAC (such as pinching the nerve with forceps or electrocoagulation) produced thoroughly distorted EcochG patterns. From the histological findings, the main causative factor for these labyrinthine damages was considered to be vascular insufficiency. The current need for neurosurgical operations to preserve hearing is discussed in the light of these findings.