Factors Prognostic for Survival in Japanese Patients Treated with Sunitinib as First-line Therapy for Metastatic Clear Cell Renal Cell Cancer.

BACKGROUND: Factors predictive of survival have been identified in Western patients with metastatic clear cell renal cell carcinoma (mCCRCC) treated with sunitinib. Less is known, however, about factors predictive of survival in Japanese patients. This study evaluated factors prognostic of survival in Japanese patients with mCCRCC treated with first-line sunitinib. MATERIALS AND METHODS: This retrospective study evaluated 46 consecutive Japanese mCCRCC patients treated with sunitinib as first line therapy. Clinical and biochemical markers associated with progression-free survival (PFS) were analyzed, with prognostic factors selected by uni- and multivariate Cox regression analyses. RESULTS: Univariate analysis showed that factors significantly associated with poor PFS included Memorial Sloan-Kettering Cancer Center poor risk scores, International Metastatic RCC Database Consortium poor risk and high (>0.5 mg/dl) serum C-reactive protein (CRP) concentrations (p<0.001 each). Multivariate analysis showed that high serum CRP was independently associated with poorer PFS (p=0.040). Six month disease control rate (complete response, partial response and stable disease) in response to sunitinib was significantly higher in patients with normal (≤0.5 mg/dl) than elevated baseline CRP (p<0.001). CONCLUSIONS: CRP is a significant independent predictor of PFS for Japanese patients with mCCRCC treated with first-line sunitinib. Pretreatment CRP concentration may be a useful biomarker predicting response to sunitinib treatment.

Methylation level of the RASSF1A promoter is an independent prognostic factor for clear-cell renal cell carcinoma.

BACKGROUND: Ras association domain family 1A (RASSF1A) is a tumor suppressor that regulates the cell cycle, apoptosis, and microtubule stability. The association between the methylation levels of RASSF1A and the prognosis of clear-cell renal cell carcinoma (CCRCC) remains unclear. Therefore, we investigated this relationship to determine the prognostic value of RASSF1A methylation levels for CCRCC. PATIENTS AND METHODS: The study comprised 179 Japanese patients who underwent radical or partial nephrectomy for CCRCC. The methylation level of 5' CpG islands in the RASSF1A was evaluated using combined bisulfite restriction analysis and bisulfite sequencing. RESULTS: High levels of methylation in the RASSF1A promoter were significantly more frequent in grade 3 compared with grade 1 or 2 tumors (P = 0.028) and in patients with stage III or IV compared with patients with stage I or II (P = 0.043). Patients with high methylation levels had a significantly less favorable prognosis compared with those with low methylation levels (P = 0.040). Higher methylation levels were independently associated with a poor prognosis following multivariate analysis (P = 0.0053). CONCLUSION: These results indicate that quantitative promoter methylation levels of the RASSF1A gene may be a useful marker to predict the prognosis of CCRCC.

Expression and function of the Delta-1/Notch-2/Hes-1 pathway during experimental acute kidney injury.

The Notch signaling pathway consists of several receptors and their ligands Delta and Jagged and is important for embryogenesis, cellular differentiation and proliferation. Activation of Notch receptors causes their cleavage yielding cytoplastic domains that translocate into the nucleus to induce target proteins such as the basic-loop-helix proteins Hes and Hey. Here we sought to clarify the significance of the Notch signaling pathway in acute kidney injury using a rat ischemia-reperfusion injury model and cultured NRK-52E cells. Analysis of the whole kidney after injury showed increased expression of Delta-1 and Hes-1 mRNA and protein along with processed Notch-2. Confocal microscopy, using specific antibodies, showed that Delta-1, cleaved Notch-2 and Hes-1 colocalized in the same segments of the injured renal proximal tubules. Recombinant Delta-1 significantly stimulated NRK-52E cell proliferation. Our study suggests that the Delta-1/Notch-2/Hes-1 signaling pathway may regulate the regeneration and proliferation of renal tubules during acute kidney injury.

The association of DNA repair gene polymorphisms with the development and progression of renal cell carcinoma.

BACKGROUND: DNA repair enzymes repair some of the DNA damage associated with risk factors for renal cell carcinoma (RCC), including smoking. DNA repair gene polymorphisms modulate the repair capacity and might influence individual risk and progression of RCC. We examined associations between functional polymorphisms and risk, clinicopathologic characteristics and survival of RCC. PATIENTS AND METHODS: The study groups comprised 215 RCC patients and 215 age- and gender-matched healthy controls. Polymorphisms in xeroderma pigmentosum complementation groups C, D and G and X-ray repair cross-complementing groups 1 and 3 genes were genotyped. RESULTS: No significant differences in DNA repair genotype were observed between RCC cases and controls. In all patients, however, greater numbers (> or =3) of total variant alleles in all DNA repair genes studied were associated with less frequent venous extension (P = 0.0079). In smokers, some genotypes were associated with characteristics of RCC (Ps < or = 0.0067) and smokers with greater numbers of total variant alleles had improved overall survival (P = 0.040). CONCLUSION: These results suggest that DNA repair gene polymorphisms may not influence RCC susceptibility, but that some of them may influence RCC progression, especially in smokers, possibly due to altered DNA repair capacity by these polymorphisms.

Single nucleotide polymorphisms in DNA repair genes might be prognostic factors in muscle-invasive bladder cancer patients treated with chemoradiotherapy.

DNA repair enzymes repair DNA damaged by platinum agents and ionising radiation. Single nucleotide polymorphisms (SNPs) in DNA repair genes modulate the repair capacity and might affect response and prognosis following platinum-based chemoradiotherapy (CRT). We investigated associations between the functional SNPs in DNA repair genes and response and survival in muscle-invasive bladder cancer patients treated with CRT to determine the predictive value of the SNPs in patient selection for bladder conservation therapy. The study group comprised 78 patients who underwent CRT for transitional cell carcinoma of the bladder. Single nucleotide polymorphisms in xeroderma pigmentosum complementation groups C (Lys939Gln, A/C), D (XPD; Lys751Gln, A/C), and G (Asp1104His, G/C), and X-ray repair cross-complementing groups 1 (XRCC1; Arg399Gln, G/A) and 3 (Thr241Met, T/C) genes were genotyped. Combined genotypes with at least one variant allele in XPD or XRCC1 were significantly associated with improved cancer-specific survival compared with remaining groups (P=0.009). In multivariate analysis, only the combined XPD and XRCC1 genotypes were independently associated with cancer-specific survival (P=0.04). The association was stronger in stage T3/T4 patients (P=0.0008). These results suggest that combined XPD and XRCC1 genotypes might be prognostic factors in muscle-invasive bladder cancer patients treated with CRT.

Vibrio vulnificus septicaemia in Japan: an estimated number of infections and physicians' knowledge of the syndrome.

Questionnaire surveys were implemented to study the incidence and physicians' knowledge of Vibrio vulnificus infections in Japan. Registered emergency physicians were selected by stratified random sampling for a questionnaire survey. A total of 235 out of 386 physicians (61%) responded to the questionnaire and 12 V. vulnificus septicaemia cases were reported from 10 respondents. The annual estimated number of V. vulnificus septicaemia was calculated as 425 (95 % CI 238-752). The study also revealed that only 15.7 % (95 % CI 11.3-21.0) of responding physicians had a basic knowledge of V. vulnificus infection. Education for both physicians and people in the high-risk group for developing the infection (e.g. immunocompromised, chronic liver disease) will be necessary for the prevention, early diagnosis and appropriate treatment of the disease.

Curved intertrochanteric varus osteotomy for osteonecrosis of the femoral head.

We reviewed the outcome of curved intertrochanteric varus osteotomy in the treatment of osteonecrosis of the femoral head in 20 hips. A mean varus angulation of 31 degrees was obtained by the osteotomy. The ratio of intact area on the weight-bearing portion increased from 19% to 61%. The mean elevation and lateral displacement of the greater trochanter were 1.2 cm and 0.5 cm, respectively. These changes in the position of the greater trochanter were very small when compared with those after conventional varus wedge osteotomy. Nonunion or delayed union was not observed. Quantitative analyses showed aggressive bone remodelling in the medial intertrochanteric region. Eighteen hips survived without collapse after a mean follow-up of 48 months. We conclude that curved varus osteotomy can be used to preserve the hip joint in patients with osteonecrosis of the femoral head.

Differential response of primitive human CD34- and CD34+ hematopoietic cells to the Notch ligand Jagged-1.

Recent reports indicate that activation of the Notch signaling pathway delays the differentiation of hematopoietic progenitors, suggesting that Notch may be used to develop novel ex vivo culture conditions for the expansion of primitive cells to be used in clinical transplantation. Here, we compare Notch expression and the effects of Jagged-1 treatment on highly purified subfractions of primitive CD34+ and CD34- human hematopoietic cells. Unlike response of cultured CD34+ cells, Jagged-1 treatment did not enhance the proliferation of CD34- cells, or promote differentiation of CD34- cells into CD34+ cells. While CD34+ and AC133-CD34- cells were shown to express all known forms of Notch receptors, Notch-3 and Notch-4 were not detected in AC133+CD34- cells. Similarly, CD34+ progeny of differentiated CD34- cells did not upregulate Notch-3 or Notch-4 upon differentiation, although transcripts for these genes were expressed in CD34+ arising from CD34+ CD38- parents, suggesting that the Notch receptor expression is tightly and differentially controlled. Fringe, known to inhibit Notch signaling in response to specific Notch ligands, was expressed in parent CD34- and CD34+ cells as well as their CD34+ progeny. We suggest that the inability of primitive CD34- cells to positively respond to Jagged-1 may be due in part to the absence of Notch-3 and Notch-4. Taken together, our study illustrates functional distinctiveness of the primitive CD34- subsets to CD34+ counterparts in relation to Jagged-1 response, and represents the first demonstration of a molecular difference among de novo isolated CD34+ compared to in vitro generated CD34+ cells arising from primitive CD34- or CD34+ parents.

Pedicle bone grafting versus transtrochanteric rotational osteotomy for avascular necrosis of the femoral head.

Segmental collapse occurs in the early stage of avascular necrosis (AVN) of the femoral head, and is associated with a poor prognosis. Since it develops at a relatively young age, the long-term outcome after total hip replacement is a major concern. We have compared the long-term results of pedicle bone grafting (PBG) with those of transtrochanteric rotational osteotomy (TRO). In the PBG group there were 23 men (27 hips) and three women (4 hips) with a mean age at the time of surgery of 38 years and a mean follow-up of 13 years. In the TRO group there were 44 men (55 hips) and 19 women (22 hips) with a mean age at the time of surgery of 39 years and a mean follow-up of seven years. Failure was defined as a need for total hip replacement or a Harris hip score below 70. The long-term results were similar for the two groups. The survival rates at five and ten years were 85% and 67%, respectively, in the PBG group, and 71% and 61%, respectively, in the TRO group, according to Kaplan-Meier survivorship analysis. In the TRO group patients in stage II had significantly better results that those in stage III.

A novel Fc receptor for IgA and IgM is expressed on both hematopoietic and non-hematopoietic tissues.

By contrast to well-defined Fc gamma and Fc epsilon receptors, the structural and functional characteristics of Fc mu receptor are unclear. We have recently described a novel mouse Fc receptor, designated Fc alpha/mu receptor, and its human homologue, which bind both IgM and IgA. Here we show that the Fc alpha/mu receptor is expressed on mature, but not immature, B lymphocytes and acquires the ability to bind IgM and IgA antibodies after stimulation of B lymphocytes. Moreover, stimulation with phorbol 12-myristate 13-acetate increased endocytosis of IgM-coated microparticles mediated by the Fc alpha/mu receptor expressed on pro-B cell line Ba/F3 cells. We also show that the Fc alpha/mu receptor is expressed in secondary lymphoid organs, such as lymph node and appendix, kidney and intestine, suggesting an important role of the receptor for immunity in these organs.

Head penetration into Hylamer acetabular liner sterilized by gamma irradiation in air and in a nitrogen atmosphere.

We reviewed 25 consecutive primary cementless total hip arthroplasties with Hylamer acetabular liners (Hylamer group) and 12 with conventional ultra-high molecular weight polyethylene (Enduron group). Two-dimensional penetration of the femoral head into the liner was determined from anteroposterior radiographs of the pelvis. Head penetration rate was 0.37 mm/y in the Hylamer group sterilized by gamma irradiation in air (n = 6; mean length of follow-up, 3 years), 0.21 mm/y in the Hylamer group sterilized by gamma irradiation in a nitrogen atmosphere (n = 19; mean length of follow-up, 2.7 years), and 0.11 mm/y in the Enduron group (n = 12; mean length of follow-up, 3.9 years). Osteolysis was identified in 6 of the 25 hips with Hylamer liners and 1 of the 12 hips with conventional liners. There was a positive linear correlation between period from production to operation and head penetration rate with Hylamer liner sterilized by gamma irradiation in air and no correlation in a nitrogen atmosphere. Rapid oxidation by irradiation in air might not be the main cause of high rate of wear in Hylamer liners.

Prediction of osteonecrosis by magnetic resonance imaging after femoral neck fractures.

Thirty-one patients undergoing internal fixation for femoral neck fractures who were examined by magnetic resonance imaging at 2, 6, and 12 months after surgery and who could be followed up more than 2 years were enrolled in the current study. The items investigated were timing of the appearance of the band image on T1 weighted images, magnetic resonance imaging classification, and plain radiographs. Band images were observed 2 months after surgery in eight patients and 6 months in 12 patients (39% of all patients). According to the location and extent of the band image on magnetic resonance imaging, one patient was classified in the B1 Group (lateral type), four patients in the B2 Group (surface type), three patients in the B3 Group (intermediate type), and four patients in the B4 Group (extended type). Band images appeared in all patients in the B4 Group 6 months after surgery. Femoral heads of the patients in the B3 and B4 Groups by magnetic resonance imaging classification all were collapsed. On plain radiographs, osteonecrosis of the femoral head could be diagnosed in eight patients between 11 and 24 months after injury. The interval giving the greatest sensitivity, specificity, and accuracy of the diagnosis of osteonecrosis of the femoral head by magnetic resonance imaging was 6 months after surgery.

Ileal neobladder for urinary bladder replacement following total pelvic exenteration for rectal carcinoma.

OBJECTIVE: The aim of this study was to determine the feasibility of using the ileal neobladder as a substitute for the urinary bladder following total pelvic exenteration for rectal carcinoma. PATIENTS AND METHODS: Between 1992 and 1998, we performed total pelvic exenteration with ileal neobladder in 5 men with rectal carcinoma. Four patients had primary tumors, and one had recurrent disease after low anterior resection for rectal carcinoma. Histological types were adenocarcinoma in 4 and squamous cell carcinoma in 1. Invaded organs were: the urinary bladder in 1, the urinary bladder and prostate in 2, the prostate and seminal vesicle in 1, and the prostate in 1. RESULTS: There was no operative death. In 1 patient, an ileal conduit was needed because of partial necrosis of the neobladder. Minor leakage on the dorsal wall of the neobladder occurred in 2 patients, which was successfully stopped with simple closure and a gluteus maximus fasciocutaneous flap, respectively. All except one patient with the ileal conduit could void via the urethra. Complete daytime urinary continence was achieved, but nocturnal continence was maintained with voiding once or twice per night. As the urodynamic state, the mean maximum flow rate was 20.9 ml/s (range 9.0-34.1), the mean average flow rate was 7.7 ml/s (range 3.0-11.0), and the mean voided volume was 285.5 ml (range 160-432). The mean length of follow-up was 47.8 months. One patient died of local recurrence 38 months postoperatively, and 1 died of pneumonia 10 months postoperatively. Both patients could void via the urethra until death. The other three patients are currently alive without any evidence of recurrence. CONCLUSIONS: Although total pelvic exenteration is a laborious surgical procedure, an ileal neobladder could be a good alternative to the urinary bladder enabling the patients to void via the urethra with urinary continence.

Human homologues of Delta-1 and Delta-4 function as mitogenic regulators of primitive human hematopoietic cells.

Delta-mediated Notch signaling controls cell fate decisions during invertebrate and murine development. However, in the human, functional roles for Delta have yet to be described. This study reports the characterization of Delta-1 and Delta-4 in the human. Human Delta-4 was found to be expressed in a wide range of adult and fetal tissues, including sites of hematopoiesis. Subsets of immature hematopoietic cells, along with stromal and endothelial cells that support hematopoiesis, were shown to express Notch and both Delta-1 and Delta-4. Soluble forms of human Delta-1 (h Delta-1) and h Delta-4 proteins were able to augment the proliferation of primitive human hematopoietic progenitors in vitro. Intravenous transplantation of treated cultures into immune-deficient mice revealed that h Delta-1 is capable of expanding pluripotent human hematopoietic repopulating cells detected in vivo. This study provides the first evidence for a role of Delta ligands as a mitogenic regulator of primitive hematopoietic cells in the human. (Blood. 2001;97:1960-1967)

The role of AIDS volunteers in developing community-based care for people with AIDS in Thailand.

The present study analyses the effectiveness of AIDS volunteers in mitigating the stigma attached to People With AIDS (PWAs) within the context of developing community-based care (CBC) in Thailand. A total of 86 trained village health volunteers (T-VHVs) and 99 non-trained village health volunteers (N-VHVs) were enrolled in the study. In addition, 58 villagers in the T-VHV's intervention area and 72 villagers in the non-intervention area were also enrolled. Both T-VHVs and N-VHVs as well as villagers were assessed to determine their level of knowledge with respect to HIV/AIDS and attitudes toward PWAs. Furthermore, we also determined the village health volunteers' level of activity in distributing knowledge of HIV/AIDS in order to prevent and reduce stigma in the community. Although T-VHVs showed a greater depth of knowledge of HIV/AIDS than N-VHVs (p < 0.05), positive attitudes toward PWAs and the level of practice of village health volunteers did not differ significantly between T-VHVs and N-VHVs. While the level of health knowledge of villagers did not differ significantly between the T-VHV's intervention and control areas, a significant difference was observed between the two areas in terms of the villagers' attitudes towards PWAs (p < 0.01). Villagers in the intervention area attached less stigma to PWAs; therefore, T-VHVs played a role in providing basic information on AIDS to the villagers and in mitigating the stigma attached to PWAs. However, these volunteers need to undergo further training through a well-organized training programme in order to obtain a greater depth of knowledge. This is essential for the development of community-based care for PWAs.

The notch ligand jagged-1 represents a novel growth factor of human hematopoietic stem cells.

The Notch ligand, Jagged-1, plays an essential role in tissue formation during embryonic development of primitive organisms. However, little is known regarding the role of Jagged-1 in the regulation of tissue-specific stem cells or its function in humans. Here, we show that uncommitted human hematopoietic cells and cells that comprise the putative blood stem cell microenvironment express Jagged-1 and the Notch receptors. Addition of a soluble form of human Jagged-1 to cultures of purified primitive human blood cells had modest effects in augmenting cytokine-induced proliferation of progenitors. However, intravenous transplantation of cultured cells into immunodeficient mice revealed that human (h)Jagged-1 induces the survival and expansion of human stem cells capable of pluripotent repopulating capacity. Our findings demonstrate that hJagged-1 represents a novel growth factor of human stem cells, thereby providing an opportunity for the clinical utility of Notch ligands in the expansion of primitive cells capable of hematopoietic reconstitution.

Fc alpha/mu receptor mediates endocytosis of IgM-coated microbes.

IgM is the first antibody to be produced in a humoral immune response and plays an important role in the primary stages of immunity. Here we describe a mouse Fc receptor, designated Fc alpha/microR, and its human homolog, that bind both IgM and IgA with intermediate or high affinity. Fc alpha/microR is constitutively expressed on the majority of B lymphocytes and macrophages. Cross-linking Fc alpha/microR expressed on a pro-B cell line Ba/F3 transfectant with soluble IgM or IgM-coated microparticles induced internalization of the receptor. Fc alpha/microR also mediated primary B lymphocyte endocytosis of IgM-coated Staphylococcus aureus. Thus, Fc alpha/microR is involved in the primary stages of the immune response to microbes.

Cartilage-derived retinoic acid-sensitive protein and type II collagen expression during fracture healing are potential targets for Sox9 regulation.

Cartilage-derived retinoic acid-sensitive protein (CD-RAP) and mRNA were examined in the mouse fracture model by immunohistochemistry and Northern blot analysis and compared with the expression of type II collagen. We also studied the expression of the transcription factor Sox9, reported to enhance type II collagen and CD-RAP gene expression in vitro. CD-RAP was first detected in immature chondrocytes on day 5. Intense signals for CD-RAP were found in fracture cartilage on days 7 and 9. CD-RAP decreased at the phase of endochondral ossification. Throughout fracture healing, CD-RAP was detected in cartilage and not in bone or fibrous tissue, thus CD-RAP may be a molecular marker of cartilage formation during fracture healing. Northern blot analysis revealed similar changes in CD-RAP and type II collagen mRNA levels. However, with respect to protein levels, CD-RAP decreased faster than type II collagen implying the stability is lower than type II collagen. Increased levels of Sox9 mRNA and protein were detected on day 5 and coincided with the initial increase of CD-RAP and type II collagen mRNAs. Sox9 mRNA levels declined with the progress of chondrocyte hypertrophy, followed by a concomitant decrease in CD-RAP and type II collagen mRNA levels. These changes in Sox9 expression compared with the cartilage-specific genes (CD-RAP and type II collagen) suggest that cell differentiation during fracture healing may be controlled by specific transcriptional factors which regulate phenotypic changes of the cells.

Trans-activation of the mouse cartilage-derived retinoic acid-sensitive protein gene by Sox9.

The transcription factor Sox9 is capable of enhancing type II collagen gene expression and may play a crucial role in chondrogenesis. To determine whether Sox9 is an inducer of the chondrocyte phenotype, we investigated the role of Sox9 in transcription of another cartilage gene encoding the cartilage-derived retinoic acid-sensitive protein (CD-RAP). CD-RAP is specifically expressed during chondrogenesis. We show here that Sox9 protein is able to bind to a SOX consensus sequence in the CD-RAP promoter. Mutation of the SOX motif led to decreased transcription of a CD-RAP promoter construct in chondrocytes. Overexpression of SOX9 resulted in a dose-dependent increased activity of CD-RAP promoter-driven reporter gene in both chondrocytes and nonchondrogenic cells. A truncated SOX9, which contains a binding domain but no trans-activation function, inhibited CD-RAP promoter activity. Overexpression of SOX9 increased the level of endogenous CD-RAP mRNA in chondrocytes, but was unable to induce endogenous gene expression in 10T1/2 mesenchymal cells or BALB/c-3T3 fibroblasts. These results suggest that Sox9 is a general transcriptional regulator of cartilage-specific genes. However, Sox9 does not appear to be able to induce the chondrocyte phenotype in nonchondrogenic cells, implying that other factors are involved in chondrogenesis.