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PDF file - 869K, Effect of DNA-PKcs or ATM inhibition on p-T2609 in NSCLCs. h pretreatment with 10 muM NU7441 or 10 muM KU55933. Square boxes represent cropped images shown in Figure 6C

MT-EGFR expression in HBEC cells is associated with dramatically elevated levels of replication factors.

PDF file - 900K, Radiation-induced T2609 phosphorylation in NSCLCs. Immuno-fluorescence detection of DNA-PKcs phosphorylation in indicated NSCLCs showing p-T2609 immunofluorescence (green) in nuclei (blue). Cropped images shown in Figure 6B

PDF file - 286K, Alterations in ATM or DNA-PKcs do not affect IR-induced nuclear import. Deficiency or inhibition of either ATM or DNA-PKcs is associated with an absence of EGFR-DNA-PKcs binding. The data in S1A eliminate the possibility that this is due to a potential abrogation of IR-induced nuclear translocation of EGFR which could prevent access to the predominantly nuclear DNA-PKcs. (A) WB of cytosolic and nuclear fractions at indicated time-points following 4 Gy IR from V3, V3-WT DNA-PKCS and V3-7A cells(A) or AT5 and 1BR3 fibroblast cells (B) expressing wild type, L858R or gammaE746-E750 EGFR showing EGFR, cytoplasmic marker, calnexin, and nuclear marker, lamin B. With exposure to 4 Gy, wild type but not L858R or gammaE746-E750 EGFR is seen in nuclear fractions of cells that lack DNA-PKcs or ATM. (C) DNA-PKcs or ATM inhibition does not affect EGFR nuclear import. WB of cytosolic and nuclear fractions at indicated time-points following 4 Gy IR from HBEC cells expressing wild type EGFR that were pretreated for 2 hours with vehicle or DNA-PKcs inhibitor, NU7441, (top panel) or ATM inhibitor, KU55933, (bottom panel). (D) Mutant forms of EGFR are also defective in binding DNA-PKcs. The data in S1A and S1B show that IR-induced nuclear translocation is completely abrogated in L858R or gammaE746-E750 forms of EGFR, which could prevent interactions with the predominantly nuclear DNA-PKcs. Here we use in vitro binding assay to demonstrate that relative to wild type EGFR, the L858R or gammaE746-E750 are also intrinsically defective in physical association with purified DNA-PKcs. In vitro binding assay: wild type, L858R or gammaE746-E750 forms of EGFR were immuno-precipitated with anti-V5 antibody from whole cell lysates from un-irradiated HBEC cells. Lane 1 from left shows no non-specific binding to beads. Antibody-bound EGFR was thoroughly washed. Lane 2 from left shows no evidence of endogenous bound protein. Antibody bound EGFR was incubated with purified human DNA-PKcs in the presence or absence of calf thymus DNA and immuno-precipitated. DNA-PKcs was detected by western blot assay. Lane 3 and 4 show that purified DNA-PKcs physically bound wild type but not the L858R or gammaE746-E750 forms of EGFR and the binding was slightly enhanced with presence of sheared calf thymus DNA.

The EGF receptor (EGFR) contributes to tumor radioresistance, in part, through interactions with the catalytic subunit of DNA-dependent protein kinase (DNA-PKc), a key enzyme in the nonhomologous end joining DNA repair pathway. We previously showed that EGFR-DNA-PKcs interactions are significantly compromised in the context of activating mutations in EGFR in non–small cell lung carcinoma (NSCLC) and human bronchial epithelial cells. Here, we investigate the reciprocal relationship between phosphorylation status of DNA-PKcs and EGFR-mediated radiation response. The data reveal that both the kinase activity of DNA-PKcs and radiation-induced phosphorylation of DNA-PKcs by the ataxia telangiectasia–mutated (ATM) kinase are critical prerequisites for EGFR-mediated radioresponse. Alanine substitutions at seven key serine/threonine residues in DNA-PKcs or inhibition of DNA-PKcs by NU7441 completely abrogated EGFR-mediated radioresponse and blocked EGFR binding. ATM deficiency or ATM inhibition with KU55933 produced a similar effect. Importantly, alanine substitution at an ATM-dependent DNA-PKcs phosphorylation site, T2609, was sufficient to block binding or radioresponse of EGFR. However, mutation of a DNA-PKcs autophosphorylation site, S2056 had no such effect indicating that DNA-PKcs autophosphorylation is not necessary for EGFR-mediated radioresponse. Our data reveal that in both NSCLCs and human bronchial epithelial cells, activating mutations in EGFR specifically abolished the DNA-PKcs phosphorylation at T2609, but not S2056. Our study underscores the critical importance of a reciprocal relationship between DNA-PKcs phosphorylation and EGFR-mediated radiation response and elucidates mechanisms underlying mutant EGFR-associated radiosensitivity in NSCLCs. Mol Cancer Res; 10(10); 1359–68. ©2012 AACR.

Supplementary Figure Legends.

PDF file - 607K, Effect of EGFR mutation status on DNA-Pkcs phosphorylation. Immuno-fluorescence detection of DNA-PKcs phosphorylation in HBEC cells stably expressing wild type, L858R or gammaE746-E750 forms of EGFR at various time-points following 4 Gy IR. Top panel: Representative images with anti-p-T2609 and anti-p-S2056 DNA-PKcs antibodies showing nuclei (blue) and phosphorylated DNA-PKcs (green). Cropped images shown in Figure 6A.

PDF file - 544K, Proximity ligation assay (PLA): Effect of DNA-Pkcs and ATM inhibition on EGFR-DNA-PKcs binding.NSCLCs or HBEC-3KT cells expressing wild type or gammaE746-E750 forms of EGFR following a 2 h pretreatment with vehicle, 10 muM NU7441 or 10 muM KU55933 were mock irradiated or exposed to 4 Gy IR and fixed at 60 minutes. Representative images of nuclei (blue) showing EGFR-DNA-PKcs complexes (intense red dots). Cropped images shown in Figure 4C

PDF file - 774K, Proximity ligation assay (PLA): To detect radiation-induced PP2A-DNA-PKcs binding. NSCLCs and HBEC cells expressing WT or gammaE746-E750 EGFR fixed 1 h following 0 Gy or 4 Gy IR. Left panel: representative images of nuclei (blue) and EGFR-DNA-PKcs complexes (red: PLA fluorescence). Square boxes represent cropped images shown in Figure 7C

PDF file - 729K, Proximity ligation assay (PLA): Effect of T2609A and S2056A on EGFR-DNA-PKcs binding. V3-WT DNA-PKCS, V3-S2056A and V3-T2609A CHO cells expressing wild type EGFR which were either mock-irradiated or exposed to 4 Gy IR. Left panel: representative images of nuclei (blue) and EGFR-DNA-PKcs complexes (red PLA fluorescence dots) after processing for PLA. Square boxes represent cropped images shown in Figure 5C.

【Background】 Resolvin E1 (RvE1) derived from the ω-3 polyunsaturated fatty acid eicosapentaenoic acid is known to be a potent pro-resolving lipid mediator that prevents chronic inflammation and osteoclastogenesis. We investigated the inhibitory effects of RvE1 on osteoclastogenesis and bone resorption to clarify its therapeutic potential for rheumatoid arthritis (RA). 【Methods】 Receptor activator of nuclear factor-κB ligand (RANKL)-induced osteoclast differentiation was assessed with tartrate-resistant acid phosphatase staining. RANKL-induced bone resorption was assessed by the measurement of pit formation using calcium phosphate-labeled fluorescent polyanionic molecules in RAW264.7 cells as osteoclast precursors. The effects of RvE1 on the RANKL-induced mRNA expression of osteoclast-specific genes and transcriptional factors such as c-fos and nuclear factor of activated T cells c1 (NFATc1) in RAW264.7 cells were measured by quantitative real-time PCR. The distribution of NFATc1 induced by RANKL was evaluated by immunofluorescence staining in RAW264.7 cells. To analyze the mechanism of the inhibitory effect of RvE1 on osteoclastogenesis, we measured IL-17-induced RANKL mRNA expression in MC3T3-E1 osteoblast cells treated with RvE1 using quantitative real-time PCR and determined the level of prostaglandin E2 (PGE2) production by enzyme-linked immunosorbent assay. 【Results】 RvE1 significantly suppressed RANKL-induced osteoclast differentiation and bone resorption. RvE1 inhibited the RANKL-induced mRNA expression of osteoclast-specific genes along with the transcription factors NFATc1 and c-fos. Moreover, NFATc1 translocation from the cytoplasm to the nucleus of RAW264.7 cells was suppressed following RvE1 treatment. RvE1 also inhibited IL-17-induced RANKL mRNA expression and PGE2 production in MC3T3-E1 cells. 【Conclusion】 RvE1 inhibited osteoclastogenesis and bone resorption by suppressing RANKL-induced NFATc1 and c-fos expression in osteoclasts and IL-17-induced RANKL expression through the autocrine action of PGE2 in osteoblasts. Our data suggest RvE1 as a new therapeutic target of RA.

EGFR signaling has been implicated in hypoxia-associated resistance to radiation or chemotherapy. Non–small cell lung carcinomas (NSCLC) with activating L858R or ΔE746-E750 EGFR mutations exhibit elevated EGFR activity and downstream signaling. Here, relative to wild-type (WT) EGFR, mutant (MT) EGFR expression significantly increases radiosensitivity in hypoxic cells. Gene expression profiling in human bronchial epithelial cells (HBEC) revealed that MT-EGFR expression elevated transcripts related to cell cycle and replication in aerobic and hypoxic conditions and downregulated RAD50, a critical component of nonhomologous end joining and homologous recombination DNA repair pathways. NSCLCs and HBEC with MT-EGFR revealed elevated basal and hypoxia-induced γ-H2AX–associated DNA lesions that were coincident with replication protein A in the S-phase nuclei. DNA fiber analysis showed that, relative to WT-EGFR, MT-EGFR NSCLCs harbored significantly higher levels of stalled replication forks and decreased fork velocities in aerobic and hypoxic conditions. EGFR blockade by cetuximab significantly increased radiosensitivity in hypoxic cells, recapitulating MT-EGFR expression and closely resembling synthetic lethality of PARP inhibition. Implications: This study demonstrates that within an altered DNA damage response of hypoxic NSCLC cells, mutant EGFR expression, or EGFR blockade by cetuximab exerts a synthetic lethality effect and significantly compromises radiation resistance in hypoxic tumor cells. Mol Cancer Res; 15(11); 1503–16. ©2017 AACR.

Background: Chronic obstructive pulmonary disease is a smoking-related disease, and is categorized into the emphysema and airway dominant phenotypes. We examined the relationship between emphysematous changes and epidermal growth factor receptor (EGFR) mutation status in patients with lung adenocarcinoma. Patients and Methods: The medical records for 250 patients with lung adenocarcinoma were retrospectively reviewed. All patients were categorized into the emphysema or non-emphysema group. Results: Wild-type EGFR was detected in 136 (54%) and mutant EGFR in 48 (19%). Emphysematous changes were observed in 87 (36%) patients. EGFR mutation was highly frequent in the non-emphysema group (p=0.0014). Multivariate logistic regression analysis showed that emphysema was an independent risk factor for reduced frequency of EGFR mutation (Odds Ratio=3.47, p=0.005). Conclusion: Our data showed a relationship between emphysematous changes and EGFR mutation status. There might be mutually exclusive genetic risk factors for carcinogenesis and development of emphysematous changes.

Background Oxidative stress plays an important role in the pathogenesis of bronchial asthma. Antioxidant nutrition and supplementation have been used to reduce oxidative stress. However, a clinical trial with antioxidant supplementation showed no beneficial effects in patients with asthma. On the other hand, physical activity is related to the prognosis of chronic obstructive pulmonary disease (COPD) and is also related to oxidant status. We investigated the relationships between oxidative stress, serum levels of vitamins, dietary vitamin intake, daily activities, and pulmonary functions in patients with asthma. Methods Eighteen patients with bronchial asthma were enrolled in this study. Reactive oxidative stress was assessed by measuring organic hydroperoxides (diacron reactive oxygen metabolites: dROM) in sera and by measuring H2O2 levels in exhaled breath condensates. The biological antioxidant capacity in serum was evaluated by measuring antioxidant potential capacity against ferric ion. We also assessed pulmonary functions, fraction of exhaled nitric oxide, serum levels of vitamins, dietary vitamin intake, and physical activities. Results There were no relationships between the index of oxidative stress (dROM and H2O2 in exhaled breathe condensates) and pulmonary functions, serum levels of vitamins, daily vitamin intakes, and activity levels in patients with asthma. Conclusion The status of transient oxidative stress may not be related to daily activities, vitamin levels, and pulmonary functions in patients with asthma in a real-life setting. However, our results were obtained in the short-term period from a small number of subjects, so a large longitudinal study is required to ascertain the relationships between oxidative stress, physical activity and vitamin intake in patients with asthma.

Immune checkpoint inhibitors (ICIs), including nivolumab, have exhibited substantial benefits in the treatment of several types of cancers. However, treatment with ICIs is often accompanied by immune-related adverse events (irAEs), and a clear understanding of the precise indications and management of irAEs is important for harnessing the full potential of these agents. While skin- or gastrointestinal-associated irAEs have been relatively well studied, there are few reports regarding nivolumab-induced cholangitis. We retrospectively reviewed data from patients with advanced or recurrent non-small cell lung cancer who were treated with nivolumab between December 2015 and December 2018 at Tottori University in Japan. Among the 59 patients, we identified four patients who experienced nivolumab-induced cholangitis. Of these four patients, stable disease (SD) was observed in two patients (50%), while partial response (PR) was achieved in two patients (50%) under nivolumab treatment. Patients were treated with corticosteroid alone (n=2) or in combination with mycophenolate mofetil (MMF) (n=2); these treatments resulted in improvements in nivolumab-induced cholangitis in three patients. In conclusion, the present retrospective study identified four cases of nivolumab-induced cholangitis. The combination of corticosteroid and MMF was effective in two cases with grade 4 nivolumab-induced cholangitis. Further reports are needed to establish the optimal management of patients with this irAE.

Background Precision medicine based on driver oncogenes is now developed for non-small cell lung cancer. Recent approval of next-generation sequencing (NGS)-based companion diagnostics has increased the need for the use of high-quality specimens for the diagnosis. Methods From August 2015 to May 2018, 82 patients who were enrolled in a nation-wide genome screening, LC-SCRUM-Japan, from our institution were examined for the success rates of genetic analysis according to sample types. A NGS analysis, Oncomine Comprehensive Assay, was performed using DNA and RNA extracted from lung cancer specimens. Results The success rates of DNA and RNA analyses were 100% (82/82 cases) and 78% (64/82), respectively. Of the 82 samples analyzed, 80 (98%) were tissues and two (2%) were pleural effusions. The success rates of RNA analysis in the 80 tissue samples were 45/60 (73%) in bronchoscopic byopsy, 10/10(100%) in operation, 5/6(83%) in Percutaneous biopsy and 3/4(75%) in others. Of the 60 bronchoscopic samples, the success rates were 72% (18/25) in EBUS-TBNA, 88% (7/8) in EBUS-GS (large diameter), 69% (11/16) in EBUS-GS (small diameter) and 82% (9/11) in direct vision biopsy. In the 82 cases analyzed, a total of 52 actionable gene alterations (18 KRAS mut, 6 EGFR mut, 6 MET amp/fus, 5 RET fus, 5 ALK fus, 4 PIK3CA mut, 2 ERBB2 mut, 2 ROS1 fus, 2 FGFR1 amp, 1 BRAF mut, 1 FGFR3 fus) were detected in 48 cases (59%). Twelve of the 48 (15%) were registered in ongoing clinical trials of targeted drugs. Conclusions All the samples were available for DNA analysis of the NGS. The success rates of RNA analysis were lower in samples obtained from EBUS-TBNA and EBUS-GS (small diameter), suggesting that the success rates depend on the sample size.

Epidermal growth factor receptor (EGFR) gene mutation testing is essential for choosing appropriate treatment options in patients with advanced non-small cell lung cancer (NSCLC). However, a time delay occurs between histological diagnosis and molecular diagnosis in clinical situations. To minimize this delay, we developed a novel point-of-care test for EGFR mutations, based on a high-speed real-time polymerase chain reaction (PCR) system designated here as ultrarapid PCR combined with highly accurate bronchoscopic sampling. We investigated whether our system for detecting EGFR mutations was valid by comparing test results with those obtained using a commercialized EGFR mutation test. We obtained small amounts of bronchial lavage fluids after transbronchial biopsies (TBBs) were performed on enrolled patients (n=168) who underwent endobronchial ultrasonography using a guide sheath (EBUS-GS). EGFR mutation analysis was performed by ultrarapid PCR immediately after EBUS-GS-TBBs were obtained (on the same day). After pathological diagnoses of NSCLC, EGFR mutation status in formalin-fixed, paraffin- embedded samples was confirmed by the PCR-invader method, and the concordance rates between the PCR methods were compared. The total diagnostic yield of EBUS-GS-TBB was 91.0%. The positive concordance rates for detecting 19del and L858R with the ultrarapid PCR and PCR-invader methods were both 100%. Negative concordance rates were 97.2 and 98.1%, respectively. We also demonstrated a dramatic effect of early erlotinib administration, based on ultrarapid PCR results, for a 52-year-old woman suffering from respiratory failure due to severe intrapulmonary metastases with poor performance status. In conclusion, ultrarapid PCR combined with EBUS-GS-TBB enabled rapid and reliable point-of-care testing for EGFR mutations.

Previously we showed that Akt-suppressing agents, combined with amrubicin, synergistically inhibited the growth of small cell lung cancer cells. The combined effects of chemotherapeutic agents and Akt-suppressing agents, including epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors, were evaluated in A549 lung adenocarcinoma cells harboring K-ras mutation and wild-type EGFR. Only amrubicin and not other chemotherapeutics (cisplatin, pemetrexed and paclitaxel) synergistically inhibited cell growth when combined with an Akt inhibitor, LY294002. The combination of amrubicin and LY294002 enhanced Annexin V binding to cells. A non-specific tyrosine kinase inhibitor, genistein, suppressed Akt and showed synergistic interaction in combination with amrubicin. Two EGFR tyrosine kinase inhibitors (EGFR-TKIs), gefitinib and erlotinib, suppressed Akt activity at clinically achievable concentrations and demonstrated synergism when combined with amrubicin. The suppression of K-ras expression by siRNA interfered with this synergism and inhibited both EGFR and Akt activity in A549 cells. In Ma10 cells, which harbor wild-type EGFR and K-ras, EGFR-TKIs neither suppressed Akt activity nor exhibited such synergism when combined with amrubicin. We concluded that the synergism by the combination of EGFR-TKI and amrubicin is attributable, at least partially, to K-ras mutation in A549 cells. The combination of EGFR-TKI and amrubicin may be a promising treatment for lung cancer with wild-type EGFR and K-ras mutation.

The EGF receptor (EGFR) contributes to tumor radioresistance, in part, through interactions with the catalytic subunit of DNA-dependent protein kinase (DNA-PKc), a key enzyme in the nonhomologous end joining DNA repair pathway. We previously showed that EGFR-DNA-PKcs interactions are significantly compromised in the context of activating mutations in EGFR in non–small cell lung carcinoma (NSCLC) and human bronchial epithelial cells. Here, we investigate the reciprocal relationship between phosphorylation status of DNA-PKcs and EGFR-mediated radiation response. The data reveal that both the kinase activity of DNA-PKcs and radiation-induced phosphorylation of DNA-PKcs by the ataxia telangiectasia–mutated (ATM) kinase are critical prerequisites for EGFR-mediated radioresponse. Alanine substitutions at seven key serine/threonine residues in DNA-PKcs or inhibition of DNA-PKcs by NU7441 completely abrogated EGFR-mediated radioresponse and blocked EGFR binding. ATM deficiency or ATM inhibition with KU55933 produced a similar effect. Importantly, alanine substitution at an ATM-dependent DNA-PKcs phosphorylation site, T2609, was sufficient to block binding or radioresponse of EGFR. However, mutation of a DNA-PKcs autophosphorylation site, S2056 had no such effect indicating that DNA-PKcs autophosphorylation is not necessary for EGFR-mediated radioresponse. Our data reveal that in both NSCLCs and human bronchial epithelial cells, activating mutations in EGFR specifically abolished the DNA-PKcs phosphorylation at T2609, but not S2056. Our study underscores the critical importance of a reciprocal relationship between DNA-PKcs phosphorylation and EGFR-mediated radiation response and elucidates mechanisms underlying mutant EGFR-associated radiosensitivity in NSCLCs. Mol Cancer Res; 10(10); 1359–68. ©2012 AACR.

症例は38歳，女性．左乳房痛と左乳房腫瘤を主訴に近医を受診し，乳腺症の診断で経過観察されていた．半年後，腫瘤が増大したため当院を受診した．視診では，乳頭上部に紫斑と乳頭陥凹が認められ，触診では左の乳頭を中心に約5.2cm大の軟らかい，可動性良好な腫瘤を触知した．CTでは内部が不均一に造影される5cm大の腫瘤が認められたが，細胞診は判別困難だった．針生検にて乳腺血管肉腫と診断され，左乳房単純切除術を施行した．切除標本では乳頭付近に皮下出血が認められ，割面では，乳頭直下に3×9cm大の腫瘤が認められた．病理診断はlow grade主体で一部intermediate gradeの乳腺血管肉腫であった．術後補助療法として胸壁照射を施行し，現在経過観察中である．乳腺血管肉腫は比較的稀な疾患であり，診断に難渋する．今回，乳腺血管肉腫の1例を経験したので報告する．

Carbon-ion radiotherapy (CIRT) holds promise to treat inoperable locally-advanced non-small cell lung carcinoma (NSCLC), a disease poorly controlled by standard chemoradiotherapy using X-rays. Since CIRT is an extremely limited medical resource, selection of NSCLC patients likely to benefit from it is important; however, biological predictors of response to CIRT are ill-defined. The present study investigated the association between the mutational status of EGFR and KRAS, driver genes frequently mutated in NSCLC and the relative biological effectiveness (RBE) of carbon-ion beams over X-rays. The assessment of 15 NSCLC lines of different EGFR/KRAS mutational status and that of isogenic NSCLC lines expressing wild-type or mutant EGFR revealed that EGFR-mutant NSCLC cells, but not KRAS-mutant cells, show low RBE. This was attributable to (i) the high X-ray sensitivity of EGFR-mutant cells, since EGFR mutation is associated with a defect in non-homologous end joining, a major pathway for DNA double-strand break (DSB) repair and (ii) the strong cell-killing effect of carbon-ion beams due to poor repair of carbon-ion beam-induced DSBs regardless of EGFR mutation status. These data highlight the potential of EGFR mutation status as a predictor of response to CIRT, i.e., CIRT may show a high therapeutic index in EGFR mutation-negative NSCLC.

原因となりうる腫瘍性病変を伴わずに腸重積を来し, 肛門外まで脱出した巨大結腸症の1例を経験したので報告する. 症例は38歳の女性で, 排便時に肛門からの腸管脱出を来し当院を受診した. 直腸診で直腸壁は保たれていることから, 直腸よりも口側の腸重積および肛門外脱出と診断し, 緊急手術を施行した. 腸重積を整復後, S状結腸を切除した. 切除腸管に腸重積の原因となる腫瘍性病変は認められなかった. 腸重積を来し肛門外まで脱出した症例は本邦では30例ほどが報告されており, すべて腸重積の原因となる腫瘍性病変を伴っていた. 自験例は巨大結腸症で, 腸重積の原因となる腫瘍性病変も伴っておらず, 非常にまれな例であった. 本症においては原因病変の有無を含めた的確な診断と, 手術の際に無理な整復を行わないことが重要である.

FDG-PETが診断に有用であった直腸癌甲状腺転移を経験したので報告する. 症例は60歳の女性で, 平成13年9月に直腸癌に対し腹会陰式直腸切断術を施行した. 平成14年1月に肺転移に対し左肺楔状切除を施行した. 術後l-LV・5-FU療法を7コース施行したが, 次第にCEAの上昇を認めたためCTおよびシンチグラムなどで全身検索を行ったが明らかな転移巣および局所再発を指摘できなかった. 12月にFDG-PETを施行したところ左頸部にFDGの集積が指摘された. 直腸癌甲状腺転移の診断で平成16年1月甲状腺左葉切除を施行した. 病理組織学的検査所見は腺癌の甲状腺転移であった. 直腸癌の甲状腺転移は非常にまれであり, 本邦報告例は自験例を含め5例であった. FDG-PETは, 従来の画像検査で異常を指摘できないが腫瘍マーカーの上昇を来している直腸癌術後患者の転移の検索に有用であると考えられた.

乳癌の消化管転移,なかでも大腸への転移は臨床では極めて稀である.われわれは乳腺浸潤性小葉癌術後で大腸転移をきたした1例を経験したので報告する.症例は45歳,女性.腹痛,嘔吐を主訴に来院し,腸閉塞と診断された.消化管造影,大腸内視鏡検査で下行結腸に完全狭窄が認められ,生検では悪性所見は認められなかったが,原発性または転移性大腸癌を考え,手術を施行した.下行結腸以外にも複数の腫瘍があり,さらにリンパ節転移や播種性病変も認められ,根治性なしと判断した.腸閉塞解除目的に腸管切除を施行し,病理組織学的検査で乳癌の転移と診断された.ゴセレリン・タモキシフェン併用療法を施行し,術後9カ月経過しSDを継続中である.乳癌患者において腹部症状の訴えの際には消化管転移の可能性を考える必要がある.また,消化管転移をきたした状態でもホルモン療法,化学療法の効果が期待できるため手術でのQOLの改善は有用である.

A 70-year-old man was admitted to our hospital because of dyspnea after taking an antihistaminic agent (homochlorcyclizine hydrochloride) for itching. Chest roentgenogram showed infiltration in the left lung field, and laboratory data revealed eosinophilia. Examination of the bronchoalveolar lavage fluid revealed an increased eosinophil count. A drug lymphocyte stimulation test was positive only for calcium stearate, an additive contained in the homochlorcyclizine hydrochloride tablet. The pulmonary infiltration and clinical symptoms subsided after withdrawal of all drugs and initiation of glucocorticoid therapy. Therefore, we concluded that this patient's pulmonary disease was caused by calcium stearate, an additive for an antihistaminic drug. An allergic reaction to a drug's additive material should be considered as a rare cause of drug-induced acute eosinophilic pneumonia.

症例は82歳,女性. 2度の分娩歴があった.突然の腹痛が出現し当科を受診,急性腹症の診断で入院となった.腹部CT検査で骨盤部に浮腫状になった腸間膜の収束像と,子宮と直腸の間に小腸のループが存在し子宮を左側に圧排している所見を認めた.以上より子宮広間膜異常裂孔ヘルニアと診断し緊急手術を施行した.開腹すると,回腸が右子宮広間膜の異常裂孔に陥入し絞扼されていた.広間膜および円靱帯を切離し絞扼を解除したが回腸の色調が不変であったため,回腸切除を施行した.左子宮広間膜を観察すると円靱帯近傍に約5mm大の異常裂孔を認めたため,円靱帯を切離して裂孔を開放し手術を終了した.術後経過は良好で第15病日に退院した.両側に異常裂孔を認めた子宮広間膜ヘルニアは非常に稀であり,文献的考察を加えて報告する.

Although cytotoxic chemotherapy is essential in epidermal growth factor receptor (EGFR)-mutated non-small cell lung cancer (NSCLC), it is unclear which regimen is most effective. We retrospectively compared the efficacy of standard platinum-based chemotherapy with that of combination chemotherapy using vinorelbine (VNR) plus dihydropyrimidine dehydrogenase-inhibitory fluoropyrimidine (DIF) in EGFR-mutated lung adenocarcinomas, and we investigated a potential mechanism by which the combination chemotherapy of VNR + DIF was favorable in the treatment of EGFR-mutated lung adenocarcinoma in vitro. In our retrospective analysis, the response rate and disease control rate afforded by the VNR + DIF treatment tended to be better than those by platinum-based chemotherapy, and the progression-free survival of the 24 VNR + DIF-treated patients was significantly longer than that of the 15 platinum-based chemotherapy patients. In EGFR-mutated PC9 cells, VNR induced EGFR dephosphorylation at a clinically achievable concentration. 1BR3-LR cells, a line of fibroblast cells transfected with a mutant EGFR construct, were completely resistant to gefitinib in the medium containing 10% fetal bovine serum (FBS), whereas the sensitivity of these cells to gefitinib was increased in 0.5% FBS-containing medium. Similarly, the sensitivity of 1BR3-LR cells to VNR was increased when they were cultured in low-serum condition. In addition, sodium orthovanadate (Na3VO4) inhibited the EGFR dephosphorylation induced by VNR or gefitinib and suppressed the cell growth inhibition by these agents in PC9 cells. VNR and gefitinib showed synergistic cell growth inhibition in combination with 5-fluorouracil (5-FU) in PC9 cells. We propose that the EGFR dephosphorylation induced by VNR is related to cell growth inhibitory activity of VNR, and that this is one of the mechanisms of the synergistic effect of VNR + 5-FU in EGFR-mutated lung cancer cells. In conclusion, the combination chemotherapy of VNR + DIF may be a promising treatment for NSCLC patients with EGFR mutations.

1988年から1998年4月までに当科で切除した胆嚢癌52例を臨床病理学的に検討し,そのリンパ節転移度から至適郭清範囲を検討した. m, mp症例は全例n0であり,胆嚢摘除術+D0-1で累積生存率100%と予後良好であった. ss以上32例におけるリンパ節転移陰性15例の累積生存率は73.1%で,陽性例の16.2%に比し有意に予後良好であった(p=0.0001).さらにss以上例をリンパ節転移度別に検討して見るとn0, n1症例の累積生存率は73.1%と予後良好でbinf0, hinf0であれば全層胆摘+D2で十分と考えられたがbinf, hinf陽性例の予後は不良で拡大手術が必要と考えられた. n2症例の累積生存率は20.8%と不良であったが,無再発生存例が2例あり,いずれもPpPD(PD)併施例で深達度ss, binf1以下, hinf2以下の症例であった. n3, n4症例は予後不良であった.現在当科ではn2(+)のss, se胆嚢癌においてhinf1-2, binf0-1であれば肝切除+PpPD(PD)+D3の良い適応と考え,胆嚢癌治療を行っている.

We have studied the expression of keratin 19 mRNA (K-19) in the axillary lymph nodes of breast cancer patients (n=100, serially from October 1997 to May 1998) in order to detect the micrometastasis by reverse transcriptase-polymerase chain reaction (RT-PCR). During the course of this study, (1) we encountered the 6 cases showing [n+, K-19(-)]. (2) To clear the discrepancy of the finding between histology and RT-PCR, some other primer pairs were used. In one case out of 6, K-19 was detected. (3) Further, the sequence of RT-PCR products showed diversity and could be roughly classified into 4 groups. Namely, group a (same sequence to the report of Genbank except for two bases), group b (almost same to group a except for one deletion and several point mutations), group c (approximate 50 bases were deleted from group a and with approximate 50 point mutations) and group d (almost same to group c except for several point mutations). Until now, we have not read the reports describing [n+, K-19(-)]. The discrepancy like these cases we experienced were partially cleared by using appropriate primer pairs.

Background The optimum dose of granulocyte colony-stimulating factor (G-CSF) for peripheral blood stem cell (PBSC) mobilization after disease-oriented, conventional-dose chemotherapy remains unknown. Methods A multicenter dose-finding study of glycosylated G-CSF (lenograstim) for the mobilization of PBSCs following adjuvant CAF chemotherapy (cyclophosphamide, doxorubicin and 5-fluorouracil) was performed in 38 patients with postoperative breast cancer. Each 10, ten and eight patients were sequentially allocated to one of the three dose groups (2, 5 and 10 micrograms/kg, respectively) of lenograstim. Lenograstim was administered subcutaneously (s.c.) daily from day 8 to the day of the last apheresis and CD34+ cells and colony-forming units-granulocyte macrophage (CFU-GMs) in peripheral blood were measured serially. Additionally, 10 patients who received adjuvant CAF chemotherapy alone also participated in the study, as a control. Results Lenograstim was well tolerated up to 10 micrograms/kg, except for one patient given 10 micrograms/kg who developed transient grade 3 hepatic enzyme elevation. The peak levels of CD34+ cells and CFU-GMs in peripheral blood showed dose-response relationships. The median peak CD34+ cells for the 0, 2, 5 and 10 micrograms/kg dose groups were 5.4, 34.3, 55.0 and 127.6 cells/microliter, respectively, and those of CFU-GMs for the 0, 2, 5 and 10 micrograms/kg dose groups were 0.01, 0.33, 1.32 and 3.30 CFU-GMs/microliter, respectively. Conclusions Considering the previous reports suggesting that a pre-apheresis number of 40-50 CD34+ cells/microliter in peripheral blood is highly predictive for achievement of more than 2.5 x 10(6) CD34+ cells/kg in a standard apheresis procedure of 10 litres, the optimum dose of lenograstim for PBSC mobilization following CAF chemotherapy in patients with postoperative breast cancer is 5 micrograms/kg/day s.c.

Forty-seven cases of phyllodes tumor of the breast (resected and diagosed pathologicaly at this hospital from 1994 to August 1997) were evaluated clinicopathologically. Thirty-nine patients were classified as benign, 5 as borderline and 3 as malignant. Eighty-one percent of all tumors found were 5cm or less in diameter, and 38 tumors were 2cm or less in diameter. In this study, no clinical findings characteristic of benign or malignant tumors were identified. Some tumors needed to be differentiated from breast cancer. If an adequate surgical margin can be achieved, it would appear that local excision is an acceptable form of primary surgical treatment

The metabolites of ethyl 4-(3,4-dimethoxyphenyl)-6,7-dimethoxy-2-(1,2,4-triazol-1-ylmeth yl)quinoline -3-carboxylate (1, TAK-603), which is under clinical evaluation as a new type of disease-modifying antirheumatic drug (DMARD), were prepared to confirm their structures and to study their pharmacological properties. Of the metabolites identified, the 4-(4-hydroxy-3-methoxyphenyl) derivative (2c, M-I) was found to have an anti-inflammatory effect in an adjuvant arthritic rat model, although its potency in this model was slightly lower than that of the parent compound.

Pancreatoduodenectomy (PD) has been applied for advanced gastric cancer with pancreatic and/or duodenal invasion. Twenty-one patients with gastric cancer underwent PD in our hospital from 1966 to 1996. No patients were lost to follow up. In this study, the clinicopathological factors and outcomes of these 21patients were analyzed. The numbers of patients with tumor invasion depths of T3 and T4 were 1 and 20, respectively. None had hepatic or peritoneal metastases, the exception being one patients who had adjacent peritoneal dissemination. Curative resection with extended lymphadenectomy beyond D2 was performed in all patients. The cumulative 1-year and 5-years survival rates were 65.2% and 41.5%, respectively. and the median survival time was 593days. There were five 5-year survivors. The survival rate in 5patients with positive lymph nodes on the posterior surface of the pancreatic head (No. 13 lymph node) was significantly lower than that in 16patients without No. 13 lymph node metastasis (p

Thirty seven patients with resectable peritoneal dissemination that were curability B in colorectal cancer were analyzed clinically and assessed factors which influence the survival. The 5-year survival rate was 31.4% and according to the multivariate analysis, there were two prognosis regulating factors included the number of disseminations of 3 and fewer and lymph node metastasis of n2 and under. Patients possess above two factors have good prognosis (survival at 5 years=56.8%). Based on prior statistical analysis. P1 and P2 divided into two groups according to the number of disseminations of 3 and fewer or 4 and over respectively. There were no statistical difference in two groups in P1. But in P2, three and fewer group had a statistically superior survival than 4 and over. And there were no statistical difference between 3 and fewer group of P2 and all of P1. These results suggest that it is appropriate that disseminations to the remole peritoneum of 3 and fewer are included P1 and 4 and over are included P2.

術前診断にて根治切除不可能と判定した進行胃癌21例に対し, 1993年より術前化学療法 (NAC) としてFLP療法 (CDDP 50mg/m2, day 1 day 8, 5FU 333mg/m2 and Leucovorin 30mg/body, day 1-8) を2クール以上施行してきた.19例に手術がなされ, 18例 (85.7%) が切除可能であった.【成績】(1) PR例は12例 (57.1%) 存在し, 根治Bとなった症例が7例存在した.(2) 部位別奏効率は, No.16リンパ節転移64.7%, 原発巣47.6%, 肝転移40%, 腹膜播種11.1%であった.(3) 21例の50%生存期間 (MST) は322日, 1生率40.5%であった.PR12例はMSTが471日で, 無効例は209日であった.(4) 根治度別では, 根治BのMST 835日に対し, 根治Cは310日で17.5か月MSTが延長していた.(5) 治療関連死亡, grade 4は1例もなく, grade 3以上の有害事象は白血球減少19.0%, 貧血14.3%, 口内炎9.5%などで安全性が確認された.【結語】FLP療法によるNACは, 非治癒因子がNo.16リンパ節転移である場合に治療効果が期待でき, PR例および根治B症例には生存率の向上も認められた.

新潟県は胃癌の多発県のひとつであり, 当院はその約1割を手術している.主に早期胃癌 (EGC) に対し, 外科的局所切除 (SLR) 112例, 腹腔鏡下楔状胃切除 (LAP) 5例, 幽門保存胃切除術 (PPG) 51例, 噴門側胃切除術 (PXG) 38例, 大網温存縮小胃切除術 (OPG) 377例を施行したので各種縮小術式につき臨床評価を加えた.【成績】(1) SLRには術後の愁訴は殆どなかった.再治療を要したのは6例 (再発2例, 多発4例) であるが, 姑息切除の1例を除き胃癌死はなく他病死を含む5生率は81.9%であった.(2) LAPには, 再発例はなく全例生存中である.(3) PPGは残胃炎, 食道炎が少なく, 体重の回復は良好であったが, 残胃への胆汁逆流は24%に認められた.再手術は2例に施行されたが, 全例外来通院中である.(4) PXGに胃癌死はないが, 5生率は84.2%である.(5) OPGは術後イレウスの発生が少なく, 現在まで原病死はない.【結語】EGCに対し, QOLの向上をはかり, 遠隔成績を損なうことなく合理的縮小手術が可能であった.

他病死を除いた2, 3型進行胃癌106例を対象に, p53蛋白の異常発現を免疫染色法 (ABC法) にて解析し, 臨床病理学的諸因子と対比しながら予後因子になりうるか否か検討した. なお, p53陽性細胞が10%以上を陽性, 10%未満を陰性と判定した. 成績:(1) p53蛋白の陽性率は47.2%であった.(2) p53陽性例の遠隔成績 (5生率40.0%) は, p53陰性例 (5生率60.7%) より明らかに不良であった.(3) 単因子解析ではリンパ節郭清度, 占居部位, T因子, N因子, P因子, H因子, t因子, n因子, ly, v, 根治度, p53が予後因子であった.(4) Coxの比例ハザードモデルによる多変量解析では, 根治度>>リンパ節転移 (n)>占居部位の順に予後に影響を与えていた. 結語: 免疫組織染色による検討にて, p53は独立した予後因子にはなりえないが, 予後不良な2, 3型進行胃癌症例の予測が可能であり, 拡大リンパ節郭清などの拡大手術やintensive chemotherapyの適応を決定する上で参考となりうる.

In a period from 1980 to 1995, we experienced 67 cases of mucinous carcinoma (3.2%) out of 2, 801 primary breast carcinomas. These 67 cases were subjected to a study of clinical features and prognosis. There were 43 pure and 24 mixed types. Mean age of the patients was 54.1±14.2 years. TNM classification almost resulted in Stage I and Stage II but one patient of pure type and one patient of mixed type were in Stage IV. Only two patients (5%) of pure type mucinous carcinoma showed lymph node metastasis. Two patients with pure type mucinous carcinoma experienced recurrence to the lung, but they are still alive, as of 11 years 2 months and 4 years 11 months after the recurrence, respectively. We suggest that if pure type mucinous carcinoma is exactly diagnosed, the operation without lymphadenectomy may be permitted.

Paraganglioma is a rare tumor arising in the paranglion tissue other than the adrenal medulla. The preoperative diagnosis of asymptomatic paraganglioma not causing excessive secretion of catecholamines is made with difficulty. We encountered a woman who was diagnosed as having a paraganglioma based on hypertension induced by operative manipulation. A 49-year-old woman visited the medical department in our hospital because of abdominal discomfort. Since close examination showed a neurogenic retroperitoneal tumor, she was admitted to the department. On laparotomy, a solid tumor (7×3×5cm) was observed between the abdominal aorta and inferior vena cava and was resected. The initiation of tumor detachment induced hypertension, and increase in the cardiac rate, and increases in all catecholamine fractions. Before the termination of tumor resection, the blood pressure decreased, and the catecholamine fraction levels were rapidly normalized. Her clinical course suggested a paraganiglioma, which was confirmed by intraoperative histopathological examination. In functional paraganglioma even in the absence of symptoms, measures against acute changes in hemodynamics during and after operation are necessary.

A retrospective review was made of 58 patients who undergoing breast-conserving surgery without radiotherapy at the department since January 1988 until July 1993. Breast-conserving surgery consisted of quadrantectomy with axillary dissection. The incidence of local recurrence was 13.8% (8 cases), There were no significant differences between the patients with local recurrence and those without local recurrence in clinical features such as age, tumor size in diameter and tumor-areolar distance. No difference was found in microscopical and biochemical findings such as incidence of cases with intraductal component, with positive estrogen receptor and with positive lymph node metastasis. So it seemed difficult to predict local recurrence. Among the patients who had undergone mastectomy immediately after breast-conserving surgery because of positive resected margin toward the nipple decided by intra-operative frozen section diagnosis, one case showed extensive intraductal involvement by carcinoma and two invasive lesions within the resected breast. It is important to exclude the cases with EIC using preoperative image diagnosis from the indication of breast-conserving surgery and to identify the extent and degree of stromal invasion, intraductal spreading and intralymphatic extention by the serial pathological examination of the resected specimen in order to decrease the incidence of local recurrence following breast-conserving surgery in the future.

[Case 1] A 55-year-old woman was seen at the department because of a mass in the right breast. The patient underwent modified radical mastectomy after confirmation of the presence of a mass 2.2 cm in diameter in the region C. The histopatological diagnosis was apocrine carcinoma. [Case 2] A 66-year-old woman was seen at the department after a disease cource of 9 years for a breast tumor. Modified radical mastectomy was performed to remove a giant cystic mass accompanied by redness and ulcer measuring 15 cm in diameter and affecting the entire right breast. Histopathological examination revealed cancer cells with abundant cytoplasm containing fine eosinophil granules, characteristic of apocrine carcinoma. In a review of the Japanese literature 39 cases of mammary apocrine carcinoma were seen. The mean age of the patients was relatively high, 58.6 years, and cases of no represented for 69.2% of them. The localized solid type was predominant, and cystic formation was found in 25.6%. Data on these previous cases show that this type of carcinoma, even when present in the form of a giant tumor, is likely to have cyst formation, and that lymph node metastasis is rare. A low grade of biological malignancy of the disease is indicated.

Epidermal growth factor receptor (EGFR) is commonly overexpressed in malignant pleural mesothelioma (MPM). Cetuximab is a chimeric mouse-human antibody targeted against EGFR and induces potent antibody-dependent cellular cytotoxicity (ADCC). The action of cetuximab against MPM cells has not been well studied. Therefore, in this study, we investigated the antitumor activity of cetuximab against MPM cell lines, particularly with respect to ADCC activity in vitro and in vivo. EGFR expression of MPM cells was measured by a quantitative flow cytometric analysis and immunohistochemistry. The effect of cetuximab on growth inhibition was assessed using a modified MTT assay. The ADCC activity was measured by a 4-h 51Cr release assay using fresh or IL-2-activated peripheral blood mononuclear cells. In vivo antitumor activity of cetuximab was evaluated using an orthotopic implantation mouse model. Cetuximab-mediated ADCC activity against MPM cells was observed at low concentration (0.25 mg/ml) and was enhanced by IL-2, whereas no direct effect on growth inhibition was detected. A logarithmic correlation was observed between the number of EGFRs on MPM cells and ADCC activity. Low EGFR expression on the MPM cells, which was weakly detectable by immunohistochemistry, was sufficient for maximum ADCC activity. In the mouse model, cetuximab treatment with or without IL-2 significantly inhibited intrathoracic tumor growth and prolonged their survival. Our study shows that cetuximab has potent anti-MPM activity both in vitro and in vivo, mainly through the immunologic mechanism of ADCC. Cetuximab has the potential to be used as a novel therapy for MPM patients.

In 2383 cases operated on for breast carcinoma at the department from April 1966 to April 1993, five cases (0.21%) of squamous cell carcinoma of the breast were experienced. Histopathologically, there were three cases of mixed type and two cases of pure type. The average age of 45.4 was younger than that of usual types and the average tumor size of 9.0cm was a little larger. One of three cases which were performed mammorgraphy, had a tumor shadow showing benign feature. On macroscopical view of section of the tumor, four cases showed circumscribed pattern, none of invasive pattern being revealed. Two cases of pure type had central necrosis. Two cases had nodal involvement, microscopically squamous cell carcinoma. One of the two cases had distant metastasis one year after the operation and another one year later died of recurrence. The remaining one case having nodal involvement is alive for 10 years and node negative patients are also alive for 10 years.