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Exon 20 insertion (Ex20Ins) mutations are the third most prevalent epidermal growth factor receptor (EGFR) activating mutation and the most prevalent HER2 mutation in non-small cell lung cancer (NSCLC). Novel therapeutics for the patients with Ex20Ins mutations are urgently needed, due to their poor responses to the currently approved EGFR and HER2 inhibitors. Here we report the discovery of highly potent and broadly effective EGFR and HER2 Ex20Ins mutant inhibitors. The co-crystal structure of compound 1 b in complex with wild type EGFR clearly revealed an additional hydrophobic interaction of 4-fluorobenzene ring within a deep hydrophobic pocket, which has not been widely exploited in the development of EGFR and HER2 inhibitors. As compared with afatinib, compound 1 a exhibited superior inhibition of proliferation and signaling pathways in Ba/F3 cells harboring either EGFR or HER2 Ex20Ins mutations, and in the EGFR P772_H773insPNP patient-derived lung cancer cell line DFCI127. Our study identifies promising strategies for development of EGFR and HER2 Ex20Ins mutant inhibitors.

Insertion mutations in EGFR and HER2 both occur at analogous positions in exon 20. Non–small cell lung cancer (NSCLC) patients with tumors harboring these mutations seldom achieve clinical responses to dacomitinib and afatinib, two covalent quinazoline–based inhibitors of EGFR or HER2, respectively. In this study, we investigated the effects of specific EGFR and HER2 exon 20 insertion mutations from NSCLC patients that had clinically achieved a partial response after dacomitinib treatment. We identified Gly770 as a common feature among the drug-sensitive mutations. Structural modeling suggested that this mutation may facilitate inhibitor binding to EGFR. Introduction of Gly770 into two dacomitinib-resistant EGFR exon 20 insertion mutants restored sensitivity to dacomitinib. Based on these findings, we used afatinib to treat an NSCLC patient whose tumor harbored the HER2 V777_G778insGSP mutation and achieved a durable partial response. We further identified secondary mutations in EGFR (T790M or C797S) and HER2 (C805S) that mediated acquired drug resistance in drug-sensitive EGFR or HER2 exon 20 insertion models. Overall, our findings identified a subset of EGFR and HER2 exon 20 insertion mutations that are sensitive to existing covalent quinazoline–based EGFR/HER2 inhibitors, with implications for current clinical treatment and next-generation small-molecule inhibitors. Cancer Res; 77(10); 2712–21. ©2017 AACR.

Purpose: Efforts to discover drugs that overcome resistance to targeted therapies in patients with rare oncogenic alterations, such as NTRK1 and ROS1 rearrangements, are complicated by the cost and protracted timeline of drug discovery. Experimental Design: In an effort to identify inhibitors of NTRK1 and ROS1, which are aberrantly activated in some patients with non–small cell lung cancer (NSCLC), we created and screened a library of existing targeted drugs against Ba/F3 cells transformed with these oncogenes. Results: This screen identified the FDA-approved drug cabozantinib as a potent inhibitor of CD74–ROS1-transformed Ba/F3, including the crizotinib-resistant mutants G2032R and L2026M (IC50 = 9, 26, and 11 nmol/L, respectively). Cabozantinib inhibited CD74–ROS1-transformed Ba/F3 cells more potently than brigatinib (wild-type/G2032R/L2026M IC50 = 30/170/200 nmol/L, respectively), entrectinib (IC50 = 6/2,200/3,500 nmol/L), and PF-06463922 (IC50 = 1/270/2 nmol/L). Cabozantinib inhibited ROS1 autophosphorylation and downstream ERK activation in transformed Ba/F3 cells and in patient-derived tumor cell lines. The IGF-1R inhibitor BMS-536924 potently inhibited CD74–NTRK1-transformed compared with parental Ba/F3 cells (IC50 = 19 nmol/L vs. > 470 nmol/L). A patient with metastatic ROS1-rearranged NSCLC with progression on crizotinib was treated with cabozantinib and experienced a partial response. Conclusions: While acquired resistance to targeted therapies is challenging, this study highlights that existing agents may be repurposed to overcome drug resistance and identifies cabozantinib as a promising treatment of ROS1-rearranged NSCLC after progression on crizotinib. Clin Cancer Res; 23(1); 204–13. ©2016 AACR.

Background The axillary reverse mapping (ARM) procedure was developed to identify and preserve arm lymphatic drainage during axillary lymph node dissection (ALND), thereby theoretically reducing the incidence of arm lymphedema. However, the oncological safety of this procedure has not yet been determined. Methods Two hundred ninety-two patients with clinically negative nodes (cN0) underwent both sentinel lymph node (SLN) biopsy and ARM. SLN was identified by dye and gamma probe methods, and ARM nodes were identified using a fluorescence imaging system. If SLN was histologically positive, ALND was performed with removal of ARM nodes. Otherwise, identified ARM nodes were preserved unless they coincided with SLN. Postoperatively, SLN as well as ARM nodes were histologically examined with H&E staining. Results SLN was identified in 286 of 292 patients, and ARM nodes were identified in 90 patients. In 54 patients with positive SLN, SLN was the same as the ARM node in 19 patients (the concordance type), whereas it was not an ARM node in the remaining 35 patients (the separate type). Non-SLN and ARM node was not involved in 51 of 54 patients with positive SLN, while it was involved in 3 patients of the concordance type. Conclusions When ARM nodes were involved in patients with cN0, these were most often the SLN-ARM nodes. Therefore, it may be concluded that ARM nodes that do not coincide with SLNs might be preserved during ALND in SLN-positive patients.

Objectives Oncogenic HER2 mutations are present in 2–4% of lung adenocarcinomas, but the relevant clinical trials are unsatisfactory. The novel HER2 inhibitor poziotinib was recently developed and clinical trials are ongoing. We compared poziotinib with nine tyrosine kinase inhibitors (TKIs), and derived poziotinib-resistant clones to investigate the resistant mechanism. Materials and methods We introduced three common HER2 mutations A775_G776insYVMA (YVMA), G776delinsVC (VC) and P780_Y781insGSP (GSP), which account for 94% of HER2 exon 20 insertions in the literature, into Ba/F3 cells. We then compared the activity of poziotinib with that of nine TKIs (erlotinib, afatinib, dacomitinib, neratinib, osimertinib, AZ5104, pyrotinib, lapatinib, and irbinitinib), determined the 90% inhibitory concentration (IC90) through a growth inhibition assay, and defined a sensitivity index (SI) as IC90 divided by the trough concentration at the recommended dose as a surrogate for drug activity in humans. We also generated resistant clones by exposure to poziotinib in the presence of N-ethyl-N-nitrosourea, and HER2 secondary mutations that might serve as a resistance mechanism were searched. Results YVMA showed resistance to all tested drugs except neratinib, poziotinib and pyrotinib. Poziotinib was the only drug with an SI less than 10 for YVMA, the most common HER2 exon 20 insertion. We established 62 poziotinib-resistant clones, and among these, only C805S of HER2, which is homologous to C797S of the EGFR, was identified as a secondary mutation in 19 clones. We also revealed that heat shock protein (HSP) 90 inhibitors show potent anti-growth activity to the C805S secondary mutant clone. Conclusions Poziotinib showed the most potent activity against HER2 exon 20 mutations. We identified the secondary C805S at the covalent binding site of HER2 to poziotinib as a potential mechanism of acquired resistance. HSP90 inhibitors might be a therapeutic strategy for the C805S secondary mutation.

High Glasgow Prognostic scores (GPSs) have been associated with poor outcomes in various tumors, but the values of GPS and modified GPS (mGPS) in patients with advanced esophageal cancer receiving chemoradiotherapy (CRT) has not yet been reported. We have evaluated these with respect to predicting responsiveness to CRT and long-term survival. Between January 2002 and December 2011, tumor responses in 142 esophageal cancer patients (131 men and 11 women) with stage III (A, B and C) and IV receiving CRT were assessed. We assessed the value of the GPS as a predictor of a response to definitive CRT and also as a prognostic indicator in patients with esophageal cancer receiving CRT. We found that independent predictors of CRT responsiveness were Eastern Cooperative Oncology Group (ECOG) performance status, GPS and cTNM stage. Independent prognostic factors were ECOG performance status and GPS for progression-free survival and ECOG performance status, GPS and cTNM stage IV for disease-specific survival. GPS may be a novel predictor of CRT responsiveness and a prognostic indicator for progression-free and disease-specific survival in patients with advanced esophageal cancer. However, a multicenter study as same regime with large number of patients will be needed to confirm these outcomes.

To clarify the alterations of tau, amyloid beta protein (A beta) 1-40 and A beta1-42(43) in the cerebrospinal fluid (CSF) that accompany normal aging and the progression of Alzheimer's disease (AD), CSF samples of 93 AD patients, 32 longitudinal subjects among these 93 AD patients, 33 patients with non-AD dementia, 56 with other neurological diseases, and 54 normal control subjects from three independent institutes were analyzed by sensitive enzyme-linked immunosorbent assays. Although the tau levels increased with aging, a significant elevation of tau and a correlation between the tau levels and the clinical progression were observed in the AD patients. A significant decrease of the A beta1-42(43) levels and a significant increase of the ratio of A beta1-40 to A beta1-42(43) were observed in the AD patients. The longitudinal AD study showed continuous low A beta1-42(43) levels and an increase of the ratio of A beta1-40 to A beta1-42(43) before the onset of AD. These findings suggest that CSF tau may increase with the clinical progression of dementia and that the alteration of the CSF level of A beta1-42(43) and the ratio of A beta1-40 to A beta1-42(43) may start at early stages in AD. The assays of CSF tau, A beta1-40, and A beta1-42(43) provided efficient diagnostic sensitivity (71%) and specificity (83%) by using the production of tau levels and the ratio of A beta1-40 to A beta1-42(43), and an improvement in sensitivity (to 91%) was obtained in the longitudinal evaluation.

The sensitivity of five kinds of cytotoxicity assays using ethanol on human hepatoblastoma cells (HUH-6 line), which were cultured as monolayers or spheroids, was compared. Ethanol was chosen as a test because it acts on cell membranes directly without being metabolized and exerts its cytotoxicity. The assay methods used were as follows: 3- (4, 5-dimethylthiazol-2-yl)-2, 5-diphenyltetrazolium bromide (MTT), lactate dehydrogenase (LDH), colony formation, cell growth and DNA assays. The sensitivity of the assays was: LDH < DNA < cell growth < MTT < colony formation. LDH assay had the advantage that the same culture could be used for multiple assays, but when a small number of cells were assayed, no significant increase in the release of LDH was detected in the assay cultures compared with the control cultures. Although the DNA and cell growth assays were more sensitive than the LDH assay, the extent of cell damage may be underestimated because the damaged cells and DNA present in the cultures are included in the assay samples. On the other hand, both MTT and colony formation assays showed a high sensitivity. The MTT assay was done within 24 h after ethanol was added to the cultures and was applicable to both monolayer and spheroid cultures, while the colony formation assay required 1-2 weeks and it was applicable only to monolayer cultures. Taken together, the MTT assay was the most suitable method to evaluate the cytotoxic effects of ethanol on HUH-6 cells cultured as either monolayers or spheroids.

This study reports long-term effects of chronic Achilles tendon rupture treatment, using reconstruction with peroneus brevis transfer (PBT), on sports activities based on an approximate 10-year follow-up study.Twenty patients (6 women and 14 men; mean age, 43 +/- 12.85 years at the time of operation) underwent chronic Achilles tendon repair with an average follow-up of 164.05 +/- 5.07 months. Seven were involved in competitive sports, 10 participated in recreational activities and three were not involved in any sporting activities. All patients were Asians. Results were assessed using Cybex strength testing and the American Othopaedic Foot and Ankle Society (AOFAS) Score, the muscle manual test (MMT), sports activities and comprehensive satisfaction assessment.Cybex strength testing resulted in an average gain of 87.05 +/- 14.83% in dorsiflexion strength (range 65-110%) and 98.05 +/- 9.02% in plantar flexion strength (range 85%-120%). The AOFAS score average was 86.9 +/- 7.27. There were no postoperative re-ruptures, no recurrences and no wound complications. Plantar flexion strength and the AOFAS score were negatively correlated with the age at the time of operation (r = -0.566, r = -0.669, respectively). Seventeen patients (85%) were level five of MMT in eversion strength. Following treatment, six patients (30%) returned to competitive sports, while 10 (50%) who, prior to the injury and surgery, were involved in recreational activities, returned to similar activities. The relatively younger group tended to continue sport activities as competitive athletes (p0.05). Significant differences were observed in age at the operation between non-satisfaction group and excellent group (p0.05). The under 40-year age group tended to show a poor value.Recreational athletes and non-athletes could return to their sports activities satisfactorily, while young competitive athletes found difficulties in certain actions, especially related to eversion.

To examine the status and clinical outcome of de-escalating antimicrobial therapy for bacteraemia due to hospital-acquired, Gram-negative bacilli that are difficult to treat. Among 1,610 patients presenting with positive blood cultures collected at our medical centre over a 6-year period, 133 were infected with Serratia, Pseudomonas, Acinetobacter, Citrobacter or Enterobacter sp. (SPACES). We examined the appropriateness of an empiric initial administration of antimicrobials based on in vitro sensitivity, and the success and outcomes of a pathogen-directed de-escalation of therapy. The treatment was considered to be successfully de-escalated when the antimicrobial spectrum was narrowed according to a spectrum ranking or when ≥2 antimicrobials prescribed initially were lowered to one agent. Outcome measures included persistent, recurrent and metastatic infections, infection-related deaths and cost of antimicrobials. The treatment was initially appropriate in 79 of 133 patients (59 %), of whom 49 (62 %) were candidates for and 28 (57 %) underwent treatment de-escalation. No treatment failure was observed among these 28 patients, while 2 of 11 patients (18 %) whose treatment was not de-escalated died (p = 0.13). The median cost of antimicrobials was €250/patient lower in the de-escalated than in the non-de-escalated group (p

This study reports the long-term surgical outcomes of elderly patients who underwent surgery using the modified Hackethal bundle nailing method on the basis of an approximately 10-year follow-up study.We treated 34 patients (7 males, 27 females) with 2- and 3-fragment fractures of the proximal humeral neck. Their ages at the time of operation ranged from 65 to 75 years (mean age, 69.5 years). They were classified as Neer group I (G-I, 8.8%), III (G-III, 79.4%) or IV (G-IV 11.8%). The duration of follow-up in patients averaged 130.6 months (range: 125.0 - 156.0 months). Patients were graded according to the Constant-Murley (CM) scoring system. Pre-operative and postoperative X-rays were also assessed.All the fractures united within 6- 9 weeks, with an average of 7.4 weeks. The mean overall Constant score was 80.0 points (G-I: 83.3; G-III: 80.5; G-IV 75.6). Among the 34 patients, 30 (88.2%) obtained excellent results and 4 (11.8%) obtained good results. Mal-union in the coronal plane was observed in two patients (6.28%) who had 160 degrees angulation in three part fracture. Mal-union of the greater tuberosity occurred in one patient (3.14%) leading to limitation of abduction to 90 degrees. There were no cases of avascular necrosis, neurovascular complications or deep infections.This study suggests that the modified H-technique is simple, less invasive, and a reliable and effective procedure for elderly patients.

Background: Neuromyelitis optica (NMO) is a demyelinating syndrome characterized by myelitis and optic neuritis. Detection of anti-NMO immunoglobulin G antibody that binds to aquaporin-4 (AQP4) water channels allows the diagnosis of a limited form of NMO in the early stage with myelitis, but not optic neuritis. However, the detailed clinicopathologic features and long-term course of this limited form remain elusive. Methods: We investigated 8 patients with the limited form of NMO with myelitis in comparison with 9 patients with the definite form. Result: All patients with limited and definite form showed uniform relapsing-remitting courses, with no secondary progressive courses. Pathologic findings of biopsy specimens from the limited form were identical to those of autopsy from the definite form, demonstrating extremely active demyelination of plaques, extensive loss of AQP4 immunoreactivity in plaques, and diffuse infiltration by macrophages containing myelin basic proteins with thickened hyalinized blood vessels. Moreover, the definite form at the nadir of relapses displayed significantly higher amounts of the inflammatory cytokines interleukin (IL)-1β and IL-6 in CSF than the limited form and multiple sclerosis. Conclusion: This consistency of pathologic findings and uniformity of courses indicates that aquaporin 4–specific autoantibodies as the initiator of the neuromyelitis optica (NMO) lesion consistently play an important common role in the pathogenicity through the entire course, consisting of both limited and definite forms, and NMO continuously displays homogeneity of pathogenic effector immune mechanisms through terminal stages, whereas multiple sclerosis should be recognized as the heterogeneous 2-stage disease that could switch from inflammatory to degenerative phase. This report is a significant description comparing the pathologic and immunologic data of limited NMO with those of definite NMO.

This report describes a case of refractory enteropathy with circulating intestinal goblet cell autoantibodies (IGA). A 19 year old man with hyperthyroidism had suffered from protracted diarrhoea for nearly 10 years. Histological examination showed evidence of collagenous enterocolitis. The diarrhoea did not improve despite fasting under total parenteral nutrition. An immunofluorescence assay demonstrated IGA without anti-enterocyte autoantibodies, the hallmark of autoimmune enteropathy, although other criteria were fulfilled. None of 109 controls, including 55 cases of inflammatory bowel disease and one of lymphocytic colitis, had IGA. This case is considered to be a variant of autoimmune enteropathy, and might be a distinct entity.

The emptying of gastric and colonic conduits following esophagectomy was evaluated. Ten consecutive patients who underwent esophagectomy for malignant diseases were divided into two groups as follows: Group I which consisted of 5 patients who underwent pyloroplasty and in whom the gastric greater curvature was used for reconstruction; and Group II which consisted of 5 patients in whom the colonic conduit was used because of previous gastrectomy. The conduits were placed in the retrosternal spaces in all the patients. The radiopaque markers swallowing test and digestive tract scintigraphy were performed to evaluate emptying two months after surgery. The radiopaque markers swallowing test demonstrated that marker rings quickly disappeared from the gastric conduits but remained in the colonic conduits for as long as three hours. Digestive tract scintigraphy demonstrated that there was no significant difference in the 60-minute clearance rate of 99mTc-DTPA from the conduits between the two groups. The results suggested that tiny food fragments remained in the haustral pockets of the colonic conduits, which may be a disadvantage of these conduits.

2'-Deoxyguanosine residues of a 3',5'-end-modified hexadeoxyribonucleotide (R-95288) with anti-HIV-1 activity were substituted with N2-methyl-2'-deoxyguanosine (m2dG). These modified oligodeoxyribonucleotides (ODNs) showed a 2-fold higher activity than R-95288. Also, the CD spectra of these ODNs indicated that the m2dG modification stabilized the tertiary structure of the G-quadruplex.

S100A6 (calcyclin) is a member of the large S100 Ca2+-binding protein family, considered to activate several processes along the calcium signal transduction pathway including the regulation of cell growth, proliferation, secretion, and exocytosis. In the present study, the distribution of S100A6 in the rat nervous system was examined by immunohistochemistry with a goat antiserum against recombinant human S100A6, which recognizes the rat S100A6 homologue. The main S100A6-immunoreactive elements were 1) neuronal somata and dendrites in some specific regions of the limbic system (e.g., the basolateral amygdaloid nucleus, ventral tip of the CA1-subicular border region, entorhinal cortex, and parasubiculum), most of which were identified as a subpopulation of pyramidal cells; 2) olfactory receptor cells and olfactory nerve fibers and terminals in the olfactory bulb; 3) some tracts of the hindbrain and spinal cord (e.g., the spinal trigeminal tract, solitary tract, dorsal root fibers, and the tract of Lissauer) and their terminals (e.g., the principal sensory trigeminal nucleus, spinal trigeminal nucleus, nucleus of the solitary tract, marginal zone, substantia gelatinosa, and proper sensory nucleus of the dorsal horn), as well as some sensory neurons of their origins in the dorsal root and trigeminal ganglia; 4) a subpopulation of astrocytes in the white matter (e.g., the corpus callosum, cingulum, external capsule, internal capsule, and fimbria of the hippocampus) and around the ventricles; 5) some ependymal cells, especially around the central canal; and 6) Schwann cells. These results will improve our understanding of the diverse function of Ca2+-binding proteins in the CNS.

A randomized controlled trial was designed to investigate the therapeutic benefit of a combination chemotherapy consisting of MTX, 5-FU and THP in patients with advanced or recurrent gastric carcinoma. The patients were randomized into two groups; Group A patients (n = 37) underwent our combined chemotherapy, whereas Group B (n = 34) underwent chemotherapy with 5-FU alone as a control. There were no significant differences in various background factors between the groups. The median survival time was roughly 170 days after the randomization for the patients with advanced cancer (n = 26 for Group A and n = 25 for Group B), with no significant difference between the groups. Two long survivors, however, belonged to Group A. The median survival time of 161 days for Group A (n = 11) was longer than that of Group B (84 days, n = 9), but the difference was not statistically significant. The incidence of toxicities (leukopenia in particular) exceeding JCOG grade 3 was significantly higher for Group A, but no morbidity was observed. These results imply that patients with advanced or recurrent gastric carcinoma may benefit from a regimen of MTX, 5-FU and THP.

Deoxyribose-moieties of modified hexadeoxyribonucleotide 1, which exhibits anti-HIV-1 activity, were partially replaced with glycerol-moieties. Compound 7 with two glycerylguanines at its 3'-end showed more potent anti-HIV-1 activity and more stability against digestion by nucleases than the parent compound 1.

Low-dose therapy consisting of cisplatin plus 5-fluorouracil was given to 20 patients with advanced gastric cancer, and specimens were obtained to evaluate levels of 5-fluorodeoxyuridine (FdUMP) and thymidylate synthase (TS), indices of DNA, and proliferating nuclear cell antigen (PCNA). There was a significant correlation between the levels of FdUMP, total TS and free TS in cancer and in normal gastric mucosa, respectively. Total TS of cancer was higher than that of normal tissue, at 5.3 +/- 4.8 and 3.4 +/- 2.2 pmol/g, respectively. On the other hand, there was no relationship nor difference between The TSIR ratio of cancer and normal mucosa. The FdUMP levels of far advanced cancer showed a tendency to be lower than those of the less advanced one, especially in liver metastasis. The total TS was higher in intestinal type and in INF alpha or beta. The free TS was higher in invasive type, liver metastasis and curability C. The TSIR ratio showed a tendency to be lower in far advanced cases, such as invasive type and INF gamma. The correlation between DNA index and TS values and between PCNA labeling index and TS values were good. These results suggest that TS levels would be a predictor for malignant potential as well as for chemosensitivity.

We have determined that hexadeoxyribonucleotides (5'TGGGAG3'), with modified aromatic groups such as a trityl group at the 5'-end, have anti-HIV-1 activity in vitro. The 6-mer bearing a 3,4-dibenzyloxybenzyl (3,4-DBB) group at the 5'-end had the most potent activity and the least cytotoxicity. When the 3'-end of the 5'-(3,4-DBB)-modified 6-mer was substituted with a 2-hydroxyethylphosphate, a 2-hydroxyethylthiophosphate, or a methylphosphate group at the 3'-end, anti-HIV-1 activity increased. Moreover, among various 3'- and 5'-end-modified 6-mers that were tested, the 6-mer (R-95288) bearing a 3,4-DBB group at the 5'-end and a 2-hydroxyethylphosphate group at the 3'-end was the most stable, when incubated with mouse, rat, or human plasma. Therefore, R-95288 was chosen as the best candidate for possible use in therapy on the basis of its anti-HIV-1 activity.

Major inclusion criteria for leukocytapheresis (LCAP) therapy were mainly insufficient response to conventional drugs therapy. LCAP was administered once a week for 5 weeks of intensive therapy and once approximately a month for maintenance therapy, for 38 patients with UC. LCAP could remove approximately 1 x 10(10) white blood cells in each session. In the evaluation, we classified the response to the LCAP as: 1) excellent, 2) moderately improved, 3) no change, and 4) deterioration. Clinical improvement was recognized in 29 of 38 patients (76%) including 8 with dramatic response during the intensive therapy, and continued throughout the maintenance therapy in 26 patients (68.4%). Even though their symptoms were mild, the patients with more than 5 years UC history seemed to be not effective. The patients with moderately improvement and with excellent response have kept remission for about 20 months and about 2.5 years on an average, respectively. Clinical and blood examinations showed no side effects in any cases. It suggests that LCAP is able to be a UC treatment between drug therapies and an operation.

Article abstract-We measured plasma levels of amyloid beta protein (A beta) ending at positions 40 (A beta 40) and 42(43) [A beta 42(43)] in six carriers of beta APP717 (Val to Ile) mutation linked to familial Alzheimer's disease (FAD) as well as in patients with sporadic AD (sAD) and controls. The percentage and the level of A beta 42(43) were significantly higher in carriers of beta APP717 mutation relative to sAD, whereas A beta 40 levels were decreased. In contrast, A beta levels and ratios were at similar levels in sAD, regardless of the stage of the disease, compared with non-AD neurologic disease controls and nondemented control individuals. These results suggest that the reported increase in the percentage of A beta 42(43) secretion in transfected cells with beta APP717 mutant genes actually takes place in the bodies of carriers of beta APP717 mutation, and that plasma A beta could be used as an indicator of the alterations of beta APP/A beta metabolism in subtypes of AD.NEUROLOGY 1997;48: 741-745

We analyzed the clinical response, toxicities, out-patient and overall survival time among 41 gastric cancer patients with peritoneal metastasis to evaluate chemotherapies and drug delivery routes. Sixteen patients were treated by arterial infusion (AI) and 25 by systemic therapy (ST), with either 5-FU/MTX (FMTX) therapy or 5-FU/CDDP (FP) therapy. Partial response was observed in 8 patients (50%) among 16 with AI and in 6 (24%) among 25 with ST (p = 0.09). There were no differences in the incidence of side effects (or = grade 2 according to WHO criteria) between AI and ST group, at 25% and 36%, respectively. No significant differences were observed in either survival time or home care duration among patients with AI chemotherapy and those with ST procedure.

Leukocytapheresis (LCAP) with a leukocyte removal filter was administered to 44 patients with inflammatory bowel disease (IBD), diagnosed as ulcerative colitis (UC) in 25 and Crohn's disease (CD) in 19. Clinical and blood examinations showed no side effects in any of the patients. During intensive therapy, clinical improvement was recognized in 21 of the 25 UC patients (84%), 8 of whom had an excellent response, and in 16 of the 19 CD patients (84.2%), 4 of whom had an excellent response. The clinical improvement continued throughout the maintenance therapy in 19 of the UC patients (76%) and in 12 of the CD patients (63.2%). In both the UC and the CD patients, flow cytometry study showed that those who had improved generally had high values for the percentages of HLADR+, HLADR+CD3+, HLADR+CD8+, and CD11a+CD8+ cells before the first LCAP, and that these values decreased to near the normal range after both intensive and maintenance therapy. In the patients who showed poor response, in contrast, the values had been at or near normal before the initial LCAP administration. The clinical improvement and the findings on flow cytometry suggest that LCAP exerts an immuno-modulatory effect and is an effective therapy for patients with IBD in whom conventional drug treatments have failed.

We analyzed the clinical response, toxicities, ambulatory and overall survival time among 51 patients with inoperable gastric cancer, to evaluate chemotherapies and drug delivery routes. Twenty-nine patients were treated by Methotrexate/5-FU (FMTX) therapy and 22 by 5-FU/CDDP (FP) therapy. Twenty-five patients were treated by intra-arterial (IA) route and 26 by intra-venous (IV). The response rate of IA therapy was higher than that of IV therapy (p0.05), 48% and 19%, respectively. Median survival times of FMTX and FP were 361 and 289 days, respectively, and the 1-year survival rates of FMTX and FP were 44% and 33%, respectively, with no significant differences. Duration of home chemotherapy with FMTX was longer than that with FP, at 130 and 85 days, respectively. There was no difference between duration of home chemotherapy of IA and that of IV. IA chemotherapy showed a higher response rate than IV, but there were no differences in the incidence of side effects and ambulatory and overall survival time.

The response of gastric cancer to intravenous application of low-dose CDDP plus 5-fluorouracil (FP) was assessed by changes in DNA indices (DIs) and PCNA labeling indices (LIs) by flow cytometry, and by the thymidylate synthetase inhibition rate (TSIR). Pretherapy samples were compared to specimens resected at operation. FP therapy was performed in 10 of 26 specimens and not in the others (C). There was no difference between change in DIs of FP group and that of C group. In FP group, PCNA LI of resected specimen was higher than that of biopsy, although they showed almost the same values in C group. Change in PCNA LIs correlated to TSIR in FP group. These results suggest that FP therapy affects gastric cancer cells in PCNA LIs and TSIR, and that PCNA LIs could be an indicator of the effect of FP therapy as TSIR.

Two cases of hepatic metastasis of colorectal cancer were treated effectively by intrahepatic-arterial infusion immunotherapy using OK-432 (2 KE/week or 2 weeks), recombinant IL-2 (35 x 10(4) JRU or 40 x 10(4) JRU/week or 2 weeks), MMC (4 mg/week or 2 weeks) and 5-FU (250 mg/day during admission, 250 mg/week or 2 weeks during outpatient treatment). The levels of CEA were decreased from 17.2 ng/ml to 2.4 ng/ml after 8 weeks in the first case (50 y. o. male) and from 521 ng/ml to 66 ng/ml after 8 weeks in the second case (36 y. o. female), respectively. Abdominal CT revealed a partial response for 11 months in the first case and 6.5 months in the second case.

Eighteen patients with gastric cancer with peritoneal metastasis were treated with methotrexate/5-fluorouracil sequential therapy. In four patients, a partial response was obtained and in another four, symptomatic relief was obtained by the therapy. As side effects, BM suppression was seen in 9 and GI symptoms in 6 patients. Intraaortic, low-dose and 3-hour-interval procedure are recommended in the therapy.

Paraffin-embedded tissue samples from 51 surgically resected, gastrointestinal smooth muscle tumors (10 leiomyomas, 5 leiomyoblastomas and 36 leiomyosarcomas) were assayed for nuclear DNA content, and the results were examined for correlation with clinico-pathological variables (tumor size, cellularity and mitosis) and prognosis. Twenty-four (47%) of the 51 tumors, consisting of 3 (30%) of the 10 leiomyomas, 2 (40%) of the 5 leiomyoblastomas and 19 (53%) of the 36 leiomyosarcomas, were identified as aneuploid. A close correlation was found between the mitotic index and the tumor size (cc= 0.528; P0.001). The DNA ploidy pattern of the leiomyosarcoma was closely correlated with the patient survival periods (P = 0.06). The estimated median survival period was 73 months for patients with diploid tumors, and 51 months for those with aneuploid tumors. The 10-year survival rate for aneuploid tumors was lower than that for diploid tumors (P0.001). The measurement of DNA content may provide an index of prognostic value in gastrointestinal leiomyosarcomas.

Sixteen patients with recurrent or unresectable gastric cancer were treated by intraarterial infusion chemotherapy. The tip of the catheter was located at the 9-10th Th level in the aorta of 14 patients and in the common hepatic artery of two. The drug combination was methotrexate + 5-fluorouracil (5-FU), cisplatin, mitomycin C (MMC) + etoposide and MMC + 5-FU. Side effects such as bone marrow suppression, diarrhea and appetite loss were seen in 63% (10/16). The response rate was 36% (4/11) in those who were evaluated, and another three showed relief from symptoms. Median survival time was 11 months, and the one year survival rate was 41%, while two patients showing PR have been alive for more than one year.

We studied light and electron microscopic findings in one case of cataract resulting from accidental radioisotope irradiation. A 53-year-old male, a radiographer, was irradiated by Ga-citrate which dropped accidentally into his left eye during a radioisotope procedure. Subsequently opacity appeared in the posterior and anterior subcapsular area of the left lens and increased in intensity. Intracapsular cataract extraction was performed one and a half years after the accident. The extracted lens was studied by light and transmission electron microscopy. Epithelial cells showed frequent stratification in some sites and disappeared in others in the equatorial region. Wedl cells and vacuoles were also seen in the posterior subcapsular area. Degeneration of lens fibers, including multilayered whorls, were observed in the cortex.

The occurrence of aneuploidy in 108 normal, benign and malignant thyroid tissues was evaluated by DNA flow cytometry. Aneuploid cell populations were found in 60% of the papillary carcinomas, 67% of the follicular carcinomas, 52% of the follicular adenomas and in 10% of the multinodular goiters. None of the non-neoplastic thyroid lesions (chronic thyroiditis and Graves' disease) showed aneuploidy. No significant differences in frequency of aneuploidy and DNA index were found between the well-differentiated and trabecular types of the papillary carcinomas (53%; 1.29 +/- 0.10 vs 75%; 1.30 +/- 0.10, respectively), although the latter type of papillary carcinomas have been shown to be associated with a more aggressive clinical behavior. Also no differences in frequency of aneuploidy were noted between the follicular carcinomas and the follicular adenomas, but the DNA index was significantly higher in the former. These findings indicate that flow cytometric analysis of DNA content may not be helpful in the evaluation of the clinical behavior of papillary carcinomas or in the determination of malignancy of follicular tumors, but may be useful in differentiating neoplastic from non-neoplastic thyroid lesions.

CDDP, MMC, UFT and Etoposide (PMUE)-combined therapy was given to a 62-year-old man with advanced gastric carcinoma. PMUE therapy consists of i.v. injection of CDDP 75 mg/m2 and MMC 10 mg/body on day 1, i.v. injection of Etoposide 50 mg/body on days 3, 4 and 5 and consecutive daily administration of UFT 400 mg/body, with 3 weeks as one course. He was admitted for Borrmann type 3 gastric carcinoma with multiple liver metastasis, lymph node metastases and peritoneal dissemination, the underwent total gastrectomy with R2 lymph node dissection. He was treated four times with this therapy after sensitivity test for carcinostatic agents (SDI test), which resulted in complete remission, as confirmed by CT scan and second-look operation. The patient has currently been free of disease, and we conclude that this PMUE therapy is extremely effective for advanced gastric carcinoma.

This study was undertaken in order to evaluate the effect of intraoperative intraperitoneal (IP) administration of cisplatin (CDDP) and/or mitomycin C (MMC) on patients who underwent an operation for gastric cancer, compared with an untreated group. There were no differences between the effect of CDDP and that of MMC. No differences were found between the survival rate of IP and untreated group in no liver and no peritoneal metastasis cases, nor in non-resection cases. However, the median survival time was longer at 377 days in IP group than at 213 days in the untreated group (p less than 0.1). The free CDDP levels in the serum after 50 mg IP injection remained effective for 15-30 min. On the other hand, the MMC levels in the serum after 20 mg IP proved in effective.

We studied the influence of the morphological mode of tumor invasion in muscularis propria (pm) layer, in 177 patients who received resection for colorectal carcinoma that invaded beyond the pm layer. Tapering Index (TI = A/B) defined from the ratio between the length of tumor invasion on upper pm layer (A) and that on lower pm layer (B), TI value was significantly lower in cases with hematogenous metastasis than that in cases without hematogenous metastasis. Cases in which TI values were under 1.3 in colon cancer and 1.9 in rectal cancer had higher possibility of synchronous or metachronous hematogenous metastasis and poorer prognosis. Therefore, we suspected that TI value would be an important factor in prediction of hematogenous metastasis.

The results of surgical treatment of patients with gastric carcinoma infiltrating into the duodenum and the pancreas head and with N3 metastases are very poor. We have employed pancreaticoduodenectomy in combination with right hemicolectomy (PD + LH) with the aim of leaving no remnant of cancer cells in the vicinity of the primary lesion, in patients with carcinomas of the distal third of the stomach, associated with duodenal invasion, presence of fixity to the pancreas head or N3 metastases, in the last ten years. Twenty-six cases were treated with this technique (Group A). These cases were compared with 63 patients who underwent subtotal gastrectomy (Group B) in the same period. The operation time, amount of blood loss and numbers of operative complications were greater in Group A than in Group B. Operating mortality was found in 2 cases in Group B but was 0 for Group A. When the survival rates were compared, PD + LH can provide better long-term results than subtotal gastrectomy, especially in the patients with tumors infiltrating into the pancreas head or metastasizing to N3. The PD + LH is a rational and safe method for the treatment of gastric carcinoma infiltrating into the pancreas head or metastasizing to N3.

Para-aortic lymph nodes (No. 16) from 21 patients with advanced gastric cancer who underwent extensive lymph node dissection, were sliced consecutively at intervals of 50 mu to study minute metastasis of No. 16 lymph nodes. Twenty-six of 30 metastatic lymph nodes had minute involvement, in which carcinoma cells were detected in marginal sinus of lymph node, microscopically. The rate of the metastases to No. 16 lymph nodes was 19% among N0-3 cases by conventional method (not consecutive slices). On the contrary, the percentage of metastasis to No. 16 lymph nodes by consecutive slices was 33% among N0-3 cases. Therefore, No. 16 nodes are involved in metastasis at high rate at operation and the extensive lymph node dissection including No. 16 nodes (R4) will be recommended to prevent lymph node recurrence caused by such a minute metastasis.

For the elucidation of the mode of action of anti-tumor agents, the cell cycle analysis of etoposide and podophyllotoxin was examined by means of the multiparameter flow cytometry using an anti-p-105 monoclonal antibody. The p-105 is one of the proliferation associated nuclear antigens and its expression increases with a cell cycle progression, especially in mitotic phase. Thus, we have applied its anti-monoclonal antibody to the discrimination between M and G2 phases of the gastric cancer cells. The results revealed that etoposide caused a G2 block and retarded an S phase transition, and podophyllotoxin caused both G2 and M phase blocks in the gastric cancer cells. This cell cycle analysis using an anti-p-105 monoclonal antibody would be a useful analysis of the antitumor agents, especially for M phase analysis of human cancer cells because of its rapidity and convenience.

Correlations of c-erbB-2 protein expression with clinical outcomes of gastric carcinomas were studied in 189 gastric carcinomas. There were 23 (12.2%) carcinomas with evidence of c-erbB-2 protein in which the reaction was localized to the cell membrane. There was no significant association between c-erbB-2 staining and the macroscopic or histologic type of the carcinomas. c-erbB-2-stained tumors were more likely to be associated with serosal invasion, nodal involvement, and peritoneal metastasis, than c-erbB-2-unstained ones. In addition, c-erbB-2 was stained in none of early gastric carcinomas. The 5-year survival rates of the c-erbB-2 protein-positive and the protein-negative group were 11% and 50%, respectively. When the c-erbB-2 tissue status and seven clinicopathologic variables as conventional prognostic factors were entered simultaneously into the Cox regression model, serosal invasion, hepatic metastasis, peritoneal metastasis, nodal status, and c-erbB-2 tissue status emerged as independent prognostic variables. The results suggested that c-erbB-2 protein expression might be enhanced in advanced stages during the progression of gastric carcinoma. In this particular group of patients, immunoreactivity for c-erbB-2 protein is an indicator of poor short-term prognosis.

The proliferative activities of 98 biopsied specimens of advanced gastric cancers were measured by the in vitro bromodeoxyuridine (BrdU) labelling method. BrdU labelling indices (LIs) varied from 4.8 to 45.1%. There was no correlation of BrdU LIs and histological type, distant metastasis, serosal invasion, macroscopic type or tumor size. However, BrdU LIs of tumors with lymph node metastases were significantly higher than those without them. Patients with tumors showing high BrdU LIs had a three-fold relative risk of death, as compared with those showing low BrdU LIs. When the BRdU LIs and all the clinicopathological parameters were entered simultaneously into the Cox model, BrdU LIs, peritoneal dissemination and serosal invasion emerged as independent prognostic parameters. These results indicate that the in vitro BrdU labelling method using biopsied materials may be useful in predicting lymph node metastasis preoperatively and designing operative procedures for individual patients.

In the last 16 years we employed pancreaticodudenectomy (PD) on 27 patients with cancers of the distal third of the stomach, associated with duodenal invasion, invasion to pancreatic head, or n3 metastasis. More recently, total gastrectomy and total pancreatectomy combined with heterotopic autotransplantation of the distal pancreas (TGTP) was performed in 7 patients with n4 metastases. These cases were compared with 56 patients who underwent subtotal gastrectomy (SG) in the same period. When the survival rates were compared, PD provided better long-term results than SG, especially on the patients with tumors infiltrating into the pancreas head. On the contrary, there was no significant survival advantage in patients with duodenal invasion or n3 metastasis between PD group and SG group. TGPT showed the longest survival for the patients with n4 metastasis. These results indicate that PD is a rational and safe method for the treatment of gastric cancer infiltrating into the pancreas head. In addition, TGTP may be the most radical procedure for the treatment of gastric cancer with n4 metastases.

Cell nuclear DNA content was determined by flow cytometric analysis in 270 patients with advanced gastric cancer. Aneuploid DNA content was observed in 150 patients (55.6%). The DNA ploidy pattern was the third significantly prognostic factor behind peritoneal dissemination and liver metastasis in Cox regression multivariate analysis. About the relationship between DNA ploidy pattern and other prognostic factors, peritoneal dissemination and wall invasion ratio of aneuploid were significantly higher than those of diploid (p less than 0.01). Five-year survival rate of diploidy patients was significantly higher than that of aneuploidy patients. In stage I, five-year survival rate of patients with diploid tumor was 83.3% and that of patients with aneuploid tumor was 70.0%. In stage II, that of patients with diploid tumor was 81.3% and that of patients with aneuploid tumor was 66.7%. In stage III, that of patients with diploid tumor was 71.2% and that of patients with aneuploid tumor was 25.1%. In stage IV, that of patients with diploid tumor was 31.6% and that of patients with aneuploid tumor was 2.6%. Furthermore in the curative case, that of patients with diploid tumor was 77.2% and that of patients with aneuploid tumor was 48.2%. Aneuploid case has significantly worse prognosis in curative operation.