Complex molecular genetic abnormalities involving three or more genetic mutations are important prognostic factors for acute myeloid leukemia.

We conducted a comprehensive analysis of 28 recurrently mutated genes in acute myeloid leukemia (AML) in 271 patients with de novo AML. Co-mutations were frequently detected in the intermediate cytogenetic risk group, at an average of 2.76 co-mutations per patient. When assessing the prognostic impact of these co-mutations in the intermediate cytogenetic risk group, overall survival (OS) was found to be significantly shorter (P=0.0006) and cumulative incidence of relapse (CIR) significantly higher (P=0.0052) in patients with complex molecular genetic abnormalities (CMGAs) involving three or more mutations. This trend was marked even among patients aged ⩽65 years who were also FLT3-ITD (FMS-like tyrosine kinase 3 internal tandem duplications)-negative (OS: P=0.0010; CIR: P=0.1800). Moreover, the multivariate analysis revealed that CMGA positivity was an independent prognostic factor associated with OS (P=0.0007). In stratification based on FLT3-ITD and CEBPA status and 'simplified analysis of co-mutations' using seven genes that featured frequently in CMGAs, CMGA positivity retained its prognostic value in transplantation-aged patients of the intermediate cytogenetic risk group (OS: P=0.0002. CIR: P<0.0001). In conclusion, CMGAs in AML were found to be strong independent adverse prognostic factors and simplified co-mutation analysis to have clinical usefulness and applicability.

Comparison of sensitivity of lung nodule detection between radiologists and technologists on low-dose CT lung cancer screening images.

OBJECTIVES: The objective of this study was to compare the sensitivity of detection of lung nodules on low-dose screening CT images between radiologists and technologists. METHODS: 11 radiologists and 10 technologists read the low-dose screening CT images of 78 subjects. On images with a slice thickness of 5 mm, there were 60 lung nodules that were ≥5 mm in diameter: 26 nodules with pure ground-glass opacity (GGO), 7 nodules with mixed ground-glass opacity (GGO with a solid component) and 27 solid nodules. On images with a slice thickness of 2 mm, 69 lung nodules were ≥5 mm in diameter: 35 pure GGOs, 7 mixed GGOs and 27 solid nodules. The 21 observers read screening CT images of 5-mm slice thickness at first; then, 6 months later, they read screening CT images of 2-mm slice thickness from the 78 subjects. RESULTS: The differences in the mean sensitivities of detection of the pure GGOs, mixed GGOs and solid nodules between radiologists and technologists were not statistically significant, except for the case of solid nodules; the p-values of the differences for pure GGOs, mixed GGOs and solid nodules on the CT images with 5-mm slice thickness were 0.095, 0.461 and 0.005, respectively, and the corresponding p-values on CT images of 2-mm slice thickness were 0.971, 0.722 and 0.0037, respectively. CONCLUSION: Well-trained technologists may contribute to the detection of pure and mixed GGOs ≥5 mm in diameter on low-dose screening CT images.

[A case of slowly progressive "pharyngeal-cervical-brachial variant of Guillain-Barré syndrome (PCB)"].

A 69-year-old woman was admitted to our hospital because of slowly progressive weakness in the neck, shoulders, proximal arms, oropharyngeal muscles. From a viewpoint of clinical course and signs, it was suspected that the patient was suffered from motor neuron disease. However, serial electrophysiological studies showed the existence of local demyelination of the motor nerves. The immunoadsorption was then performed and marked recovery of symptoms was obtained. In this case, we could not detect any established anti-ganglioside antibodies which was related to pharyngeal-cervical-brachial variant of Guillain-Barré syndrome(PCB) or Guillain-Barré syndrome (GBS). It is suggested that unknown anti-ganglioside antibody may play an important role in cases of PCB. Despite of atypical slowliness of clinical progression and negative results of immunological studies, this patient is considered to be suffered from PCB, because of the results of electrophysiological studies and effectiveness of immunoadsorption therapy. Accordingly it may be important to take the possibility of PCB into diagnostic consideration, whenever the patient shows slowly progressive weakness in proximal arms, oropharyngeal muscles.

Impact of immediate cerebral angiography for in-hospital cerebral thromboembolism after cardiovascular surgery.

OBJECTIVES: Postoperative stroke remains a serious problem in cardiovascular surgery. We studied the role of cerebral angiography in postcardiotomy stroke. METHODS: We retrospectively analyzed 5 in-hospital patients with stroke due to cerebral thromboembolism after cardiovascular surgery. RESULTS: The incidence of in-hospital cerebral thromboembolism was 0.5%, involving 5 patients among 913 adults undergoing cardiovascular operations. In-hospital cerebral thromboembolism occurred 3 to 9 days (average: 7 +/- 2 days) after surgery. Causes of cerebral thromboembolism were chronic atrial fibrillation in 1, transient atrial fibrillation in 2, artificial valve in 1, and intracranial arterial stenosis in 1. Immediate cerebral angiography, after exclusion of intracranial hemorrhage and complete cerebral infarction by computed tomography, revealed cerebral embolism in 3 and cerebral thrombosis in 2 with occlusion or stenosis of intracranial arteries. Local intraarterial administration of a thrombolytic agent was done in the 3 patients with cerebral embolism and occluded arteries were recanalized. Fibrinolysis was not done in 2 because of recanalized arteries or sufficient peripheral blood supply through collateral feeders. No patients exhibited rebleeding into the pericardial space or wound bleeding. All patients survived with moderate or full functional recovery. CONCLUSION: Immediate cerebral angiography with/without local thrombolysis may improve functional outcome and survival in patients with postcardiotomy cerebral thromboembolism.

[A case with cerebral subcortical hemorrhage following the administration of phenylpropanolamine].

A 21-year-old woman experienced severe headache and nausea one hour after taking pills containing 160 mg of phenylpropanolamine for common cold. She had no previous history of drug abuse or hypertension. Physical examination revealed slight left-sided hemiparesis. Her blood pressure was 100/52 mmHg. Subcortical hemorrhage was noted in the right frontal lobe with a cranial computed tomography. On the seventh hospital day, cerebral angiography demonstrated with segmental narrowing of a branch of the right anterior cerebral artery, indicating the presence of focal angitis. This finding disappeared on the 35th hospital day. In the majority of the reported cases of the intracerebal hemorrhage associated with the ingestion of phenylpropanolamine, focal angitis rather than induced hypertension is considered to be a causative factor for hemorrhage. Thus, we would like to emphasize that the administration of phenylpropanolamine should be avoided, even to the patients without hypertention or past history of intracerebral hemorrhage.

Contribution of CD95 ligand-induced neutrophil infiltration to the bystander effect in p53 gene therapy for human cancer.

Clinical trials of adenoviral p53 gene therapy provide the evidence that the bystander effect induced by the wild-type p53 gene transfer on adjacent tumor cells contributes to tumor progression; its mechanism, however, remains uncharacterized. We report in this work that injection of adenovirus expressing the human wild-type p53 gene (Ad5CMVp53) into established human colorectal tumors in nu/nu mice resulted in CD95 ligand (CD95L) overexpression, followed by a massive neutrophil infiltration. Culture supernatants of human colorectal cancer cells infected with Ad5CMVp53 exhibited a potent chemotactic activity against murine polymorphonuclear neutrophils, which could be abolished by the anti-CD95L mAb (NOK-1). In vivo cell depletion experiments indicated that neutrophils were in part responsible for the antitumor effect of the Ad5CMVp53 infection. Our data directly suggest that overexpression of CD95L by the wild-type p53 gene transfer induces neutrophil infiltration into human colorectal tumors, which may play a critical role in the bystander effect of p53 gene therapy.

[Usefulness of diffusion-weighted MRI in the diagnosis of transient ischemic attacks].

Diffusion-weighted imaging(DWI) has been demonstrated to be valuable for assessment of ischemic stroke patients. The aim of this study is to evaluate clinical usefulness of DWI in the diagnosis of transient ischemic attack(TIA). Nineteen patients with symptoms of TIA were studied. DWI was taken with 1.5 Tesla MRI system using spin echo EPI sequence. Seven patients revealed areas of hyperintensity (brightness) on DWI and of hypointensity on apparent diffusion coefficient(ADC) maps relative to normal brain. As the duration of TIA symptom elongated, the percentage of patients with DWI abnormalities became higher. DWI enabled to detect areas of hyperintense lesion in all three patients as early as 3 hours after the onset, while conventional T2 weighted imaging showed in one. All the DWI abnormalities were irreversible in spite of the complete recovery from TIA. DWI is an useful technique for the detection of responsible lesions in TIA. However, TIA cannot be ruled out even if DWI does not demonstrate any abnormal signals.

A new tumor-rejection antigen recognized by cytotoxic T lymphocytes infiltrating into a lung adenocarcinoma.

Lung cancer is the most commonly occurring malignancy worldwide and one of the few that continues to show an increasing incidence. To understand the molecular basis of host immunity against lung cancer, we investigated tumor antigens recognized by HLA-A24-restricted CTLs established from T cells infiltrating into lung adenocarcinoma and report a new gene coding for antigens recognized by the CTLs. The mRNA of this gene was expressed at different levels in all of the malignant cells tested (high in adenocarcinomas and gliomas and low in esophageal cancers and malignant hematological disease). It was also expressed at the different levels in each of a panel of normal tissues (high in the thymus, low in peripheral blood mononuclear cells, and lowest in the stomach, small intestine, and skeletal muscle). This gene encodes a Mr 60,000 nuclear protein with 414 deduced amino acids. The three peptides at positions 158-165, 170-179, and 188-196 were recognized by the CTLs. One peptide at position 188-196 had the ability to induce HLA-A24-restricted and tumor-specific CTLs in peripheral blood mononuclear cells of lung cancer patients. These CTLs, however, did not lyse HLA-A24+ PHA-activated T cells in which the mRNA of this gene was highly expressed, even in the presence of excess amounts of a corresponding peptide in culture. These results suggest that this gene product and peptide could be applicable to specific immunotherapy of lung cancer patients.

Identification and genetic mapping of RAPD markers linked to the densonucleosis refractoriness gene, nsd-2, in the silkworm, Bombyx mori.

In the silkworm, Bombyx mori, nonsusceptibility to B. mori densonucleosis virus type-2 (BmDNV-2) is controlled by a recessive gene, nsd-2 (nonsusceptibility to DNV-2). We investigated the genetic linkage between two random-amplified polymorphic DNA (RAPD) markers and the +nsd-2 gene. Initially, we constructed the JSD-2 strain (nsd-2/+), which is congenic to strain J137 (nsd-2/nsd-2) with respect to the chromosome containing the +nsd-2 gene, starting with a female of strain J137 and a male of strain C137 (+nsd-2/+nsd-2). Genomic DNAs were compared between infected individuals of the JSD-2 strain and J137 by a polymerase chain reaction (PCR) with 700 arbitrary 10-mer primers. Two RAPD markers (OPH19R and OPP01R) linked to the +nsd-2 gene were found. For the crossing-over experiment, a female of J137 was crossed with a male (nsd-2/+) of JSD-2. Segregation analysis showed that the most closely linked RAPD marker (OPP01R) was mapped 4.7 cM distant from +nsd-2.

Extended septoplasty for subaortic stenosis developed 19 years after double-outlet right ventricle repair.

A 27-year-old woman developed subaortic stenosis 19 years after double-outlet right ventricle repair. Subaortic stenosis was caused by a narrow ring of fibromuscular ridge associated with a bulge of the underlying septal muscle. The aortic valve was bicuspid and stenotic. We conducted extended septoplasty, replacing the aortic valve. Postoperative cineangiogram showed an adequate left ventricular outflow pathway. Double-outlet right ventricle repair may thus be followed by subaortic stenosis as long as 19 years after initial surgery. This lesion was assumed due to acquired disease secondary to flow disturbances in the left ventricular outflow, so reconstructing an adequate outflow pathway is effective and appears to help avoid recurring stenosis.

Bilateral radial arterial T graft and the left thoracotomy approach for second redo coronary artery bypass grafting.

We herein report a case of third coronary artery bypass grafting (CABG) using a bilateral radial artery T graft. There were patent grafts on the anterior aspect of the heart other than the occluded left internal thoracic artery to the left anterior descending (LAD) artery. A T shaped bilateral radial artery conduit was anastomosed from the left subclavian artery to the LAD and first diagonal branch through a left thoracotomy approach. Postoperative angiography demonstrated excellent flow of radial artery conduits. Left thoracotomy with the use of a bilateral radial artery T graft is a useful substitute for anterior re-sternotomy entry in redo CABG.

Identification of a new endoplasmic reticulum-resident protein recognized by HLA-A24-restricted tumor-infiltrating lymphocytes of lung cancer.

To help clarify the molecular basis of tumor immunology in lung cancer, we have investigated antigens recognized by HLA-A24-restricted CTLs established from T cells infiltrating into lung adenocarcinoma and report a new gene encoding tumor epitopes recognized by the CTLs. This gene was located on chromosome 4q31.22 and encoded an unreported endoplasmic reticulum-resident protein with 412 deduced amino acids. This protein had a molecular mass of 46 kDa and was expressed in the majority of malignant cells and tissues tested, with the exception of T-cell leukemia cells, but was not expressed in a panel of normal cells and tissues, except in those of the testis, placenta, and fetal liver. Two peptides at positions 13-20 and 75-84 were recognized by the CTLs and had an ability to induce HLA-A24-restricted and tumor-specific CTLs in peripheral blood mononuclear cells of lung cancer patients. Thus, these peptides might be appropriate molecules for use in the specific immunotherapy of HLA-A24+ patients with lung and other cancers.

Induction of human leukocyte antigen-A26-restricted and tumor-specific cytotoxic T lymphocytes by a single peptide of the SART1 antigen in patients with cancer with different A26 subtypes.

Peptide antigens available for use in specific immunotherapy of patients with cancer have not been fully determined. Although the authors have reported the SART1 gene encoding epitopes recognized by HLA-A2601-restricted and tumor-specific cytotoxic T lymphocytes (CTLs), the HLA-A26 allele is mainly subdivided into A2601, A2602, and A2603 subtypes. In this study, the authors attempted to determine whether the SART1-derived peptide at position 736-744 (KGSGKMKTE) is suitable to induce HLA-A26-restricted and tumor-specific CTLs in patients with cancer who have these subtypes. This peptide induced the HLA-A26 subtype-restricted and tumor-specific CTLs in HLA-A2601+ or HLA-A2603+ peripheral blood mononuclear cells, respectively. It also induced the HLA-A26-restricted CTL activity in HLA-A2602+ peripheral blood mononuclear cells. Therefore, this peptide could be useful for specific immunotherapy of patients with cancer who have any of the three HLA-A26 subtypes.

Percutaneous vertebral angioplasty before coronary artery bypass grafting.

We report a case of a 63-year-old male with three-vessel coronary heart disease complicated by stenosis of the bilateral vertebral arteries. Triple coronary bypass grafting, using arterial conduits, was successfully performed after percutaneous balloon angioplasty of the left vertebral artery. Precedent angioplasty of a stenotic vertebral artery is safe and protects the brain from ischemia during extracorporeal circulation.

Establishment and epitope analysis of allo-specific cytotoxic T lymphocytes at a tumor site recognizing a spouse's HLA-A0206 molecule.

PROBLEM: The molecular basis of allo-reactivity in reproductive immunity has not been fully clarified. METHOD OF STUDY: Cytotoxic T lymphocytes (CTLs) were established from tumor-infiltrating lymphocytes (TILs). The allo-reactivity of the CTLs against various tumor cell lines or human leukocyte antigen (HLA)-A allele-transfected COS-7 cells was measured by 51Cr-release or interferon-gamma production assay. RESULTS AND CONCLUSIONS: We have established CTLs reacting to an HLA-A0206 molecule that matched a spouse's HLA-A allele from the TILs of a 68-year-old multiparous patient with gastric cancer. The amino acids at positions 66 and 88 in the alpha1 domain of HLA-A0206, both of which were common in the other HLA-A2 subtypes, were involved in the recognition by the CTLs. Endogenous peptides in the groove were not involved in the recognition. These results suggest the presence of long-lasting memory CTLs raised by the reproduction process, and may facilitate a better understanding of the molecular basis of allo-recognition during reproduction.

Regional alterations in an excitatory amino-acid transporter, blood flow, and glucose metabolism after middle cerebral artery occlusion in the rat.

A rise in the extracellular concentration of excitatory amino acids (EAA) plays a pivotal role in ischemic brain injury. EAA concentrations are regulated by uptake mechanisms through high-affinity EAA transporters. Since EAA uptake is energy-dependent, it is a matter of interest to explore the relationship between the EAA transporter and derangement of flow-metabolism during ischemia. We examined the regional changes in EAA transporters after permanent occlusion of the middle cerebral artery in rats by in vitro autoradiography using [3H]-D-aspartate as a ligand, and correlated these changes to the local cerebral blood flow (LCBF) and local cerebral glucose metabolism (LCMRglc) determined by in vivo double-labeled autoradiography. The values of specific binding of [3H]-D-aspartate decreased maximally by 20% in the ischemic core. The magnitude of the reduction in specific binding correlated well with the changes in LCBF and LCMRglc. In half of the regions with LCMRglc between 80 and 120% of the intact side, the values of the specific binding were relatively preserved, while in the remainder of the regions in the ischemic hemisphere, with LCMRglc ranging from 40 to 160% of the intact side, there was a reduction in specific binding. These results suggest that energy failure and the related perturbation caused by ischemia can decrease EAA uptake capacity, leading to further deterioration.

Acute heart failure due to local dehiscence of aortic wall at aortic valvular commissure.

Spontaneous dehiscence of the aortic wall at the aortic commissure is not recognized as one of the usual pathological causes of aortic regurgitation. We describe the case of a 56-year-old man with hypertension, who experienced acutely progressive congestive heart failure due to massive aortic regurgitation. Local layer dehiscence around the commissure was noted with partial detachment of the commissure resulting in the loss of commissural support with secondary rupture of a non-coronary cusp, which led to massive aortic regurgitation.

Carotid and aortic screening for coronary artery bypass grafting.

BACKGROUND: To identify risk factors for preexisting carotid and aortic disease in coronary artery bypass grafting (CABG), preoperative parameters were analyzed. METHODS: Three-hundred eight consecutive patients undergoing elective isolated CABG were investigated through preoperative duplex scanning of the carotid artery, computed tomography of the chest, and intraoperative ultrasonography of the ascending aorta. RESULTS: Prevalence of carotid stenosis and ascending aortic atherosclerosis was 14.3% (44 of 308) and 30.2% (93 of 308), respectively. Multivariate analysis indicated that significant independent risk factors for carotid stenosis were atherosclerosis of the ascending aorta (p = 0.028, odds ratio [OR] = 2.16), peripheral vascular disease (p = 0.008, OR = 4.08), and history of stroke (p = 0.0004, OR = 3.73). Significant independent risk factors for ascending aortic atherosclerosis were peripheral vascular disease (p = 0.029, OR = 3.05), age older than 60 years (p = 0.009, OR = 2.94), and carotid stenosis (p = 0.018, OR = 2.27). Modifications on the operative procedure for aortic atherosclerosis were carried out in 49 patients. Overall hospital mortality and morbidity for stroke were 0.97% and 0.65%, respectively. CONCLUSIONS: Prevalence of carotid and aortic disease was not low among candidates for CABG. Carotid and aortic screening may help to modify the operative strategy to reduce morbidity of stroke.

Late aneurysm of the distal aortic arch after repair of aortic interruption. A case report.

Aneurysm formation after aortic coarctation repair is not a rare complication of post-coarctation of aorta repair. We describe the case of a 43-year-old woman who had undergone repair of an isolated interruption of the aortic arch 30 years earlier, who came to our hospital with progressive chest pain, cough and dyspnea. A giant aortic aneurysm was revealed in the distal aortic arch by CT study. The patient underwent aneurysmectomy with total aortic arch replacement using a Dacron graft through redo median sternotomy. An embryologic explanation of this patient's anomaly and the previous surgical procedure are discussed for defining this rare clinical condition.

A cyclophilin B gene encodes antigenic epitopes recognized by HLA-A24-restricted and tumor-specific CTLs.

We have studied Ags recognized by HLA class I-restricted CTLs established from tumor site to better understand the molecular basis of tumor immunology. HLA-A24-restricted and tumor-specific CTLs established from T cells infiltrating into lung adenocarcinoma recognized the two antigenic peptides encoded by a cyclophilin B gene, a family of genes for cyclophilins involved in T cell activation. These two cyclophilin B peptides at positions 84-92 and 91-99 induced HLA-A24-restricted CTL activity against tumor cells in PBMCs of leukemia patients, but not in epithelial cancer patients or in healthy donors. In contrast, the modified peptides at position 2 from phenylalanine to tyrosine, which had more than 10 times higher binding affinities to HLA-A24 molecules, could induce HLA-A24-restricted CTL activity against tumor cells in PBMCs from leukemia patients, epithelial cancer patients, or healthy donors. PHA-activated normal T cells were resistant to lysis by the CTL line or by these peptide-induced CTLs. These results indicate that a cyclophilin B gene encodes antigenic epitopes recognized by CTLs at the tumor site, although T cells in peripheral blood (except for those from leukemia patients) are immunologically tolerant to the cyclophilin B. These peptides might be applicable for use in specific immunotherapy of leukemia patients or that of epithelial cancer patients.