順天堂醫事雑誌...June 2015 The Juntendo Medical Society 2－1－1 Hongo Bunkyo-ku, Tokyo, 113－8421 JAPAN Tel：+81－3－5802－1586 E-mail：[email protected] Juntendo

June 2015

The Juntendo Medical Society2－1－1 Hongo Bunkyo-ku, Tokyo, 113－8421 JAPAN

Tel：+81－3－5802－1586　E-mail：[email protected]

Juntendo Medical Journal

The Cutting Edge of Intravascular Treatment/Farewell Lectures of Retiring ProfessorJune 2015

The Juntendo M

edical Society

順天堂醫事雑誌

Juntendo Medical Journal　Vol. 61　No. 3　p. 216－348 Tokyo 2015. 6 61－3（896th issue）

ISSN　2187－9737　CODEN：JIZUA2 61（3）216―348（2015）

613

－

Foundedin 1875

What’s New from Juntendo University, TokyoJuntendo University Radiofrequency Ablation Training Program Shuichiro Shiina, et al.

Health Topics for Tokyoites: The Cutting Edge of Intravascular TreatmentDevelopment of Intra-Arterial Chemoembolization for Various Types of Cancer in Humans 　 Ryohei Kuwatsuru, et al.Development of Endovascular Therapy for Intracranial Aneurysms Hidenori OishiEndovascular Treatment for Ischemic Stroke Munetaka Yamamoto, et al.Endovascular Treatment of Gastrointestinal Bleeding Akihiko Shiraishi

Special Reviews: Farewell Lectures of Retiring ProfessorFuture Chemotherapy Preventing Emergence of Multi-Antibiotic Resistance 　 Keiichi Hiramatsu, et al.New Biomarkers for Diagnosis in Patients with Chronic Kidney Disease (CKD) Yasuhiko TominoRehabilitation in Juntendo University: Past, Present and Future Masanori NagaokaA Personal Research Chronicle for 41 Years at Juntendo University Takashi UenoA Retrospective of My 40 Years of Research on Mosquito Ovarian Development; 　Amino Acids, Not Solely an Element of Yolk Protein Synthesis, 　But an Activating Factor of Oogenesis Keikichi Uchida

Original ArticlesUsefulness of BCSH Criteria for Diagnosing Japanese Polycythemia Vera 　―Comparative Analysis with WHO 2008 Criteria― Yuriko Yahata, et al.Diversity of Arterial Branches in the Crural and Foot Region as Correlated with 　the Relative Thickness of the Fibular and Posterior Tibial Arteries Shiki Machida, et al.

Case ReportsAzuki Bean Allergy in a Japanese Child: a Case Report Kiyotaka Ohtani, et al.

Lecture NotesFunctional MRI Research on Memory Consolidation and Memory Retrieval Circuit Seiki Konishi

Medical EssaysSearching for the Greatest Treasure Jean Hino

Juntendo Research ProfilesDepartment of Neurology, Department of Gastroenterology, Department of Cellular and Molecular

Pharmacology, Department of Respiratory Medicine, Department of Metabolism and Endocrinology, Division of Nephrology, Department of Internal Medicine, Department of Obstetrics and Gynecology, Department of Hematology

Publication ListPublications from Juntendo University Graduate School of Medicine, 2013 [1/6]


Editor-in-Chief: Isao Nagaoka

Editorial Board: Machiko Hatsuda Eri Hirasawa Toshiaki IbaKazuo Kaneko Shunsuke Kato Hiroyuki KobayashiSeiki Konishi Ryohei Kuwatsuru Takashi MiidaToshihiro Mita Sachiko Miyake Akira MurakamiMasanori Nagaoka Takumi Ochiai Kazuhisa TakahashiRobert F Whittier Kazuhito Yokoyama

Illustration: Akiko Miyamichi

Published by The Juntendo Medical Society Printed by Shinkosha Printing Co. Ltd.2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan 19-2 Sarugaku-cho, Shibuya-ku, Tokyo 150-0033 JapanTEL 03-5802-1586 E-mail [email protected] TEL 03-3462-1182 E-mail [email protected]Ⓒ The Juntendo Medical Society 2015 Tokyo Japan20150630

The History of Juntendo Medical Journal

This Juntendo Medical Journal has been published under the Japanese name Juntendo Igaku (順天堂医学)from 1964 to 2012. However, the origin of Juntendo Medical Journal dates back to the oldest medical journalin Japan, Juntendo Iji Zasshi (順天堂醫事雑誌), which had been published between 1875 and 1877 (total of 8issues). Between 1885 and 1886, Juntendo issued a limited release of a research journal titled Houkoku[Juntendo Iji Kenkyukai](報告) for a total of 39 issues.

In 1887, Juntendo Iji Kenkyukai Houkoku (順天堂醫事研究會報告) was published with the governmentʼsapproval and we used to regard this as the first issue of Juntendo Medical Journal. Since then, JuntendoMedical Journal has undergone a series of name changes: Juntendo Iji Kenkyukai Zasshi (順天堂醫事研究会雑誌), Juntendo Igaku Zasshi (順天堂医学雑誌), and Juntendo Igaku (順天堂医学).

Now in commemoration of the 175th anniversary of Juntendo University, starting with the first volumeissued in 2013 (Volume 59 Number 1), we return to Juntendo Medical Journalʼs original Japanese title in1875-Juntendo Iji Zasshi (順天堂醫事雑誌). We also reconsidered the numbering of the journal and set thefirst issue in 1875 as the initial publication of Juntendo Medical Journal. The Volume-Number countingsystem and the English name Juntendo Medical Journal started in 1955 from the January 10 issue. Althoughthis is not our intension, we will retain the Volume-Number counting system to avoid confusion. However,Volume 59 Number 1 will be the 882nd issue, reflecting the sum of all issues to date: 8 issues of Juntendo IjiZasshi (順天堂醫事雑誌), 39 issues of Houkoku [Juntendo Iji Kenkyukai](報告)(47 issues combined), and834 issues from Juntendo Iji Kenkyukai Houkoku (順天堂醫事研究會報告) in 1887 to the present.

出典：小川秀興（OGAWAHideoki, M.D., Ph.D.）：順天堂醫事雑誌（Juntendo Medical Journal）2013；59：6-10.

本誌は昭和39年（1964年）から平成24年（2012年）末まで『順天堂医学』として刊行されてきた．しかし，その起源は明治8年（1875年）から10年（1877年）にかけて発刊された日本最古の医学誌『順天堂醫事雑誌』（計8巻）にある．さらに明治18年（1885年）から19年（1886年）まで，会員限定配本として順天堂醫事研究會の雑誌『報告』（計39集）が発行されている．

その後『順天堂醫事研究會報告』が明治20年（1887年）に官許を受けて公刊されたので，順天堂ではこれを通刊1号としてきた．以来，『順天堂醫事研究会雑誌』，『順天堂医学雑誌』，『順天堂医学』と名称を変更して刊行されてきた．

今般，順天堂が創立175周年を迎える平成25年（2013年）の59巻1号を期して，本来の名称である『順天堂醫事雑誌』と復刻し，その起源である明治8年（1875年）第1巻をもって創刊号（通刊第1号）とすることとした．従来の巻号と欧文誌名は，昭和30年（1955年）1月10日発行のものを1巻1号としており，欧文誌名もこれより付け始めたもので不本意であるが，混乱を避けるためにこれらを継承する．ただし，通刊数は明治8年（1875年）から19年（1886年）にかけて刊行された『順天堂醫事雑誌』8巻分と順天堂醫事研究會の雑誌『報告』39集，計47巻分を通巻834号に加え，59巻1号を通刊882号とした．

出典：小川鼎三，酒井シヅ：順天堂医学 1980；26：414-418.

小川秀興：順天堂醫事雑誌 2013；59：6-10.

Contents

Whatʼs New from Juntendo University, Tokyo

Juntendo University Radiofrequency Ablation Training Program ㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀Shuichiro Shiina, et al. ㌀㌀㌀㌀㌀㌀㌀216

Health Topics for Tokyoites: The Cutting Edge of Intravascular Treatment

Development of Intra-Arterial Chemoembolization for Various Types of Cancer in Humans㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀Ryohei Kuwatsuru, et al. ㌀㌀㌀㌀㌀㌀㌀220

Development of Endovascular Therapy for Intracranial Aneurysms ㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀Hidenori Oishi ㌀㌀㌀㌀㌀㌀㌀228Endovascular Treatment for Ischemic Stroke ㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀Munetaka Yamamoto, et al. ㌀㌀㌀㌀㌀㌀㌀235Endovascular Treatment of Gastrointestinal Bleeding ㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀Akihiko Shiraishi ㌀㌀㌀㌀㌀㌀㌀242

Special Reviews: Farewell Lectures of Retiring Professor

Future Chemotherapy Preventing Emergence of Multi-Antibiotic Resistance ㌀㌀㌀㌀㌀㌀Keiichi Hiramatsu, et al. ㌀㌀㌀㌀㌀㌀㌀249New Biomarkers for Diagnosis in Patients with Chronic Kidney Disease (CKD) ㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀Yasuhiko Tomino ㌀㌀㌀㌀㌀㌀㌀257Rehabilitation in Juntendo University: Past, Present and Future ㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀Masanori Nagaoka ㌀㌀㌀㌀㌀㌀㌀264A Personal Research Chronicle for 41 Years at Juntendo University ㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀Takashi Ueno ㌀㌀㌀㌀㌀㌀㌀272A Retrospective of My 40 Years of Research on Mosquito Ovarian Development; Amino Acids,Not Solely an Element of Yolk Protein Synthesis, But an Activating Factor of Oogenesis㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀Keikichi Uchida ㌀㌀㌀㌀㌀㌀㌀280

Original Articles

Usefulness of BCSH Criteria for Diagnosing Japanese Polycythemia Vera-Comparative Analysis withWHO 2008 Criteria- ㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀Yuriko Yahata, et al. ㌀㌀㌀㌀㌀㌀㌀287

Diversity of Arterial Branches in the Crural and Foot Region as Correlated withthe Relative Thickness of the Fibular and Posterior Tibial Arteries ㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀Shiki Machida, et al. ㌀㌀㌀㌀㌀㌀㌀294

Case Reports

Azuki Bean Allergy in a Japanese Child: a Case Report ㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀Kiyotaka Ohtani, et al. ㌀㌀㌀㌀㌀㌀㌀302

Lecture Notes

Functional MRI Research onMemory Consolidation andMemory Retrieval Circuit ㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀Seiki Konishi ㌀㌀㌀㌀㌀㌀㌀305

Medical Essays

Searching for the Greatest Treasure ㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀Jean Hino ㌀㌀㌀㌀㌀㌀㌀307

Juntendo Research Profiles

Publication List

Publications from Juntendo University Graduate School of Medicine, 2013 [1/6] ㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀326

Instruction to Authors ㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀342Editorʼs Note ㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀347

Vol. 61 No. 3 (896th issue)June 2015

The Juntendo Medical Society

JUNTENDOMEDICALJOURNAL

Department of Neurology ㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀309Department of Gastroenterology ㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀312Department of Cellular and Molecular Pharmacology

㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀314Department of Respiratory Medicine ㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀315

Department of Metabolism and Endocrinology ㌀㌀㌀㌀㌀㌀318Division of Nephrology, Department ofInternal Medicine ㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀320

Department of Obstetrics and Gynecology ㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀322Department of Hematology ㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀㌀324

Juntendo University Radiofrequency Ablation Training Program

SHUICHIRO SHIINA＊1), RYO SHIMIZU＊1), MANABU HAYASHI＊1), KOKI SATO＊1),

NOBUHITO TANIKI＊1), RYO KANAZAWA＊1), HIROKO MIURA＊1), SHIGETO ISHII＊1),

TAKESHI HATANAKA＊1), JIN-KAN SAI＊1), HIRONAO OKUBO＊2)

＊1)Division of Diagnostic Imaging and Interventional Oncology, Juntendo University Graduate School of Medicine, Tokyo,

Japan, ＊2)Department of Gastroenterology, Juntendo University Nerima Hospital, Tokyo, Japan

Radiofrequency ablation (RFA) plays an important role in the treatment of liver tumors. Juntendo University is

now the highest-volume center for RFA in Japan, which obliges us to teach technical aspects of RFA skills to

doctors in other institutions and standardize the RFA procedure. In order to provide an opportunity to understand

the basic concept and learn essential technical tips for successful ablation, we held a training program at Juntendo

University on October 31st and November 1st, 2014. The quota for the program was filled instantly. Eighteen

doctors from various regions of Japan participated in it. The program had comprehensive lectures, live

demonstration and case study. We performed RFA on three patients. Through the two-day intensive course, the

participants learned the current status of RFA. A questionnaire survey after the program revealed

overwhelmingly positive feedback from the participants. We plan to hold this program several times a year. We

would also like to hold a longer-term training program, such as for 2 weeks. Additionally, we would like to have an

international training program in which we would accept foreign doctors in the near future.

Key words: radiofrequency ablation, training program, live demonstration, hepatocellular carcinoma, liver

tumor

Hepatocellular carcinoma

Hepatocellular carcinoma is the fifth most com-

mon malignant neoplasm in the world 1). Surgery

plays a limited role in its treatment, in contrast to

other solid tumors. Only 20%-30% of patients can be

candidates for hepatectomy because of underlying

cirrhosis or multiple lesions 2). Furthermore, this

cancer frequently recurs even after apparently

curative resection because of latent metastasis or

metachronous multicentric carcinogenesis. Conse-

quently, various nonsurgical therapies have been

introduced.

Radiofrequency ablation

Among nonsurgical therapies, radiofrequency

ablation (RFA) has been widely accepted as the

best treatment option for patients with small

hepatocellular carcinoma 3) 4). In RFA, the electrode

is inserted into the tumor under image guidance.

Then, radiofrequency energy emitted from the

exposed portion of the electrode is converted into

heat and causes necrosis of the tumor. Our

experience shows that RFA is a locally curative

treatment, resulting in survival for more than 10

years, and a safe procedure. However, RFA is

highly operator-dependent. Outcomes are very

different from operator to operator, or from

institution to institution.

Juntendo University is now the highest-volume

center for RFA in Japan (Figure-1), which obliges

us to teach technical aspects of RFA skills to

doctors in other institutions and standardize the

216

Corresponding author: Shuichiro Shiina

Division of Diagnostic Imaging and Interventional Oncology, Juntendo University Graduate School of Medicine

2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan

TEL: +81-3-3813-3111 E-mail: [email protected]

〔Received Dec. 10, 2014〕

Whatʼs New fromJuntendoUniversity,Tokyo

Juntendo Medical Journal2015. 61(3), 216-219

RFA procedure. In order to provide an opportunity

to understand the basic concept and learn essential

technical tips for successful ablation, we held the

third training program at Juntendo University on

October 31st and November 1st, 2014. We had

similar training programs at Juntendo University

on June 14th and 15th, 2013, and August 22nd and

23rd, 2014.

Participants

We had announced that the course would not be

for beginners but for intermediate or advanced

doctors who can perform RFA independently. The

quota of the program was set to 18.

We limited the number of participants because of

the nature of the training and the space of the

Juntendo Medical Journal 61(3), 2015

217

Figure-1 Monthly number of RFA cases at Juntendo, Japan

The new system for RFAstarted at Juntendo.

Jan－12

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Feb－13

Jan－13

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Oct－12

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Aug－12

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0

70

60

50

40

30

20

10

Figure-2 Participants in the 3rd Juntendo University radiofrequency ablation training program

Teine Keijinkai HospitalDr. TsujiDr. Tanaka

Osaka Medical Centerfor Cancer and

Cardiovascular DiseasesDr. Kimura

Osaka City UniversityDr. UchidaDr. Kawamura

Kyoto UniversityDr. Ueda

Niigata UniversityDr. Kamimura

Tohoku UniversityDr. Kondo

Osaka Medical CollegeDr. Tsuchimoto

Osaka GeneralMedical CenterDr. Hasegawa

Mito Medical CenterDr. Shimoyamada

Showa UniversityKoto Toyosu Hospital

Dr. Nomura

Showa UniversityNorthern Yokohama Hospital

Dr. Baba

Yokohama MunicipalCitizen’s HospitalDr. Komatsu

Shizuoka Municipal HospitalDr. Kodaka

Shikoku Cancer CenterDr. AsagiKumamoto Medical Center

Dr. Sugi

Obihiro－KoseiGeneral HospitalDr. Morita

RFA-dedicated room. The program was popular

because there had been no such programs in which

they could receive practical training of RFA at a

high-volume center. The quota of 18 was filled

within two weeks after recruitment started. Those

who applied after the quota had been filled were

asked to apply for future programs.

Eighteen doctors from various regions of Japan

participated in the program (Figure-2). There

were 16 male and 2 female doctors. Eleven were in

their 30s, four in their 40s, and three in their 50s.

Eight worked for university hospitals and 10 for city

hospitals. Seventeen were physicians and the

remaining one a radiologist.

Program contents

The program had comprehensive lectures, live

demonstration and case study (Table-1). The

contents of the lectures were the current status of

RFA, RFA devices, ultrasonography, indications

and complications of RFA, nursing practice in RFA,

RFA for metastatic liver cancer, and image

assessment of cases before and after RFA (Fig-

Shiina, et al: Juntendo University radiofrequency ablation training program

218

October 31-November 1, 2014

Day-1

Time Program Moderator

14 : 00 Opening remarks & course introduction Shuichiro Shiina

14 : 10 Lecture: Overview of RFA Shuichiro Shiina

14 : 30 Lecture: RFA device (Cool-tip) Century Medical

14 : 50 Lecture: Ultrasonography Philips Japan

15 : 10 Coffee breaks

Lecture: RFA for metastatic liver cancer Takamasa Oki (Mitsui Memorial Hospital)

15 : 50 Lecture: Nursing practice in RFA Rika Chino (Chief Nurse of the Gastroenterology Ward)

16 : 10Case presentation, planning, and ultrasound examinationsfor the next-day live demonstration

Nobuhito Taniki, Ryo Shimizu & All

19 : 30 Welcome party All

Day-2

8 : 30Live demonstration of RFA on three patients with livertumors

Shuichiro Shiina, Nobuhito Taniki & Ryo Shimizu

12 : 30Luncheon presentation & discussion of difficult to ablatecases from participantsʼ hospitals

All

13 : 30 Lecture: Indications & complications of RFA Ryosuke Tateishi (University of Tokyo)

14 : 10 Lecture: Image assessment of cases before & after RFA Shuichiro Shiina

15 : 00Presentation & discussion of difficult to ablate cases fromJuntendo University

All

16 : 00 Conferment of certificates & closing remarks Shuichiro Shiina

Table-1 Juntendo University radiofrequency ablation training program schedule

Figure-3 A comprehensive lecture at the training program Figure-4 A live demonstration of radiofrequency ablation

ure-3).

The live demonstration included the presentation

of three cases on which we would perform RFA the

following day, and planning ultrasound examina-

tions conducted by participants on the first day. On

the second day, we performed RFA on the three

cases, using an artificial ascites technique, con-

trast-enhanced ultrasound guidance and a fusion

imaging method (Figure-4). We also showed how

we compare and evaluate CT images before and

after RFA.

In the case study, a total of 12 difficult-to-ablate

cases from the participantsʼ hospitals and ours were

presented and discussed (Figure-5). The partici-

pants understood that the treatment outcome may

be influenced by the physiciansʼ expertise and the

institutionʼs volume of care.

At the end of the program, there was a closing

ceremony, in which a certificate was conferred on

each participant (Figure-6). Through the two-day

intensive course, the participants learned the

current status of RFA.

Evaluation of the program

A questionnaire survey after the program

revealed overwhelmingly positive feedback from

the participants. Many participants remarked on

the benefit of being directly trained by the noted

interventional oncologists in an academic environ-

ment where interaction between teachers and

students and group discussions were encouraged.

Future perspective

We plan to hold this program several times a

year, and are having the next program on February

20th and 21st, 2015. We would also like to hold a

longer-term training program, such as for 2 weeks.

Additionally, we would like to have an international

training program in which we would accept foreign

doctors in the near future. For the details, please see

our divisionʼs homepage (http://www.juntendo.ac.

jp/graduate/laboratory/labo/gazo_shindan/).

References

1) Parkin DM, Bray F, Ferlay J, Pisani P: Estimating theworld cancer burden: Globocan 2000. Int J Cancer, 2001;94: 153-156.

2) Borie F, Bouvier AM, Herrero A, et al.: Treatment andprognosis of hepatocellular carcinoma: a populationbased study in France. J Surg Oncol, 2008; 98: 505-509.

3) Shiina S, Teratani T, Obi S, et al.: A randomizedcontrolled trial of radiofrequency ablation with ethanolinjection for small hepatocellular carcinoma. Gastroen-terology, 2005; 129: 122-130.

4) Shiina S, Tateishi R, Arano T, et al.: Radiofrequencyablation for hepatocellular carcinoma: 10-year outcomeand prognostic factors. Am J Gastroenterol, 2012; 107:569-577.


219

Figure-5 An example of a difficult to ablate case78-year old woman underwent radiofrequency ablation for

hepatocellular carcinoma in the caudate lobe at another hospital.

Local tumor progression was found 8 months later. The patient

was referred to our hospital, because they thought that the

recurrent tumor was difficult to be treated by ablation at that

hospital. The tumor (arrow) was largely contiguous to the

inferior vena cava, and adjacent to the middle and right hepatic

veins, and porta hepatis.

Figure-6 A closing ceremony of the program

Development of Intra-Arterial Chemoembolization for Various Types of Cancer in Humans

RYOHEI KUWATSURU＊1), SHINICHI HORI＊2)

＊1)Department of Radiology, Juntendo University Faculty of Medicine, Tokyo, Japan, ＊2)Department of Radiology, Gate

Tower Institute for Image Guided Therapy, Osaka, Japan

Intra-arterial chemoembolization has been performed for more than 30 years as a standard anti-cancer therapy

for unresectable cases of hepatocellular carcinoma. Recent developments in diagnostic machines and the advent of

micro-catheters, micro-guidewires, and new embolic agents (such as microspheres) have enabled this technique

to be used for the treatment of other tumors, such as lung cancer, breast cancer, liver metastasis, lung metastasis,

lymph node metastasis, and bone metastasis. This review article describes these developments in intra-arterial

chemotherapy, with a focus on liver tumors and pulmonary tumors.

Key words: transarterial chemoembolization, hepatocellular carcinoma, liver metastasis, pulmonary tumor,

computed tomography during angiography

Introduction

Intra-arterial chemotherapy, i.e., direct infusion

of anticancer drugs to a tumor-feeding artery, has

been performed for many cancers 1)-4). High-density

injection of anticancer drugs into tumors through

arteries has the potential to induce a strong chemo-

therapeutic effect; however, intra-arterial chemo-

therapy is not popular for most cancers because of

the difficulty of the procedure.

Recent developments in micro-catheters and

micro-guidewires have enabled superselective

catheter insertion and injection of anti-cancer

drugs directly into the the tumor-feeding artery (i.

e., avoiding adjacent normal tissue) 1)-3). Small

embolic agents such as microspheres are now

available to embolize the tumor-feeding arteries

during or after injection of anti-cancer drugs to

enhance the drug effect 5) 6). Even simply blocking

tumor-feeding arteries with small embolic agents,

without anti-cancer drugs, sometimes has anti-

cancer effects due to ischemia, especially in

vascular-rich tumors 7)-10).

Angiography accompanied with computed

tomography (CT) is suitable to confirm the precise

distribution of anti-cancer drugs. Recently, recon-

struction of CT-like images from 4-dimensional

fluoroscopic data using cone-beam CT, has become

available in some angiographic machines to confirm

the distribution area and to facilitate precise arterial

embolization 11)-13). In this review article, develop-

ments in intra-arterial chemotherapy are

described.

Micro-catheters and micro-guidewires

Catheters used about 30 years ago were mostly

6-7 Fr (diameter, 2-2.3 mm) or sometimes larger.

These large catheters were difficult to insert into

small arteries, and troubles at the puncture site,

such as bleeding, hematoma, and pseudoaneurysm,

were frequent. Because precise insertion of the

catheter into small arteries was impossible, precise

transarterial chemoembolization was not per-

formed. The development of catheter introducers to

help control catheter movement has lessened the

220

Corresponding author: Ryohei Kuwatsuru

Department of Radiology, Juntendo University Faculty of Medicine


TEL: +81-3-3813-3111 FAX: +81-3-3812-3738 E-mail: [email protected]

35th Health Topics for Tokyoites: The Cutting Edge of Intravascular Treatment〔Held on Feb. 21, 2015〕

〔Received July 8, 2015〕

Health Topics forTokyoites


trouble at puncture sites. Catheter size has also

been reduced, with 4-5 Fr (diameter, 1.3-1.7 mm)

catheters becoming mainstream.

Furthermore, micro-catheters (1.6-2.7 Fr; diame-

ter, 0.5-0.9mm) and micro-guidewires (0.010-0.016

inches; diameter, 0.3-0.4 mm) have been invented

(Figure-1) ; each of these inserts into the catheter

and enters the small arteries through the tip of the

catheter. Several sizes of micro-catheters are now

widely used, and superselective embolization has

become relatively easy.

Microspheres

For more than 40 years, transcatheter chemoem-

bolization has been performed for hepatocellular

carcinoma (HCC) with the use of oily contrast

medium (lipiodol) or lipiodol plus anticancer drug

emulsion and sponge-based embolic materials that

dissolve within two weeks after injection 14)-17).

Lipiodol passes easily through the small arteries to

the targeted lesion. Lipiodol accumulation depends

on the arterial flow: it accumulates particulary well

in vascular-rich HCCs, but its accumulation in the

normal liver tissue has little detrimental effect

because it washes out in two weeks. Sponge-based

embolic materials are additionally used to extend

the time of embolization. Because the sponge-based

material is large and its size is inconsistent, precise

embolization of the tumor and tumor-feeding

arteries is difficult. Furthermore, since the diameter

of the sponge is larger than that of the tumor-feed-

ing arteries, embolization usually occurs due to the

blockade of the proximal tumor-feeding arteries. In

some such cases, collateral arteries develop and

arterial blood flow communicates to the distal site of

the tumor-feeding artery; this results in wash out

of lipiodol or lipiodol plus anti-cancer drug emul-

sion―the tumor fed by the new collateral arteries

remains alive.

Because microspheres are small with little

variation in size (Figure-2), tumors and tumor-

feeding arteries are embolized precisely without

proximal embolization. Also, because some anti-

cancer drugs can be embedded in the microspheres,

drugs can be released gradually, making their

effects stronger and more sustained. Microsphere

embolization just after infusion of anticancer drugs

is also common choice for chemoembolotherapy.

CT during angiography

After injection of the contrast agent in angiogra-

phy, it is sometimes difficult to evaluate whether a

tumor is enhanced or not if there is only faint

enhancement. Strongly enhanced tumors are easy

to recognize, but differentiation of the tumor from

normal hypervascular tissue is sometimes difficult.

Transcatheter arterial chemoembolization (TACE)

with microspheres is successful if the anticancer

drug and embolic agent distributes only to the

lesion; however, if a large volume of normal tissue is

included in the embolic area, severe infarction or

inflammation may occur in normal tissue and


221

Figure-1 Micro-catheter and micro-guidewireAn example micro-catheter (arrow; 0.7 mm in diameter) and

micro-guidewire (arrowhead; 0.4 mm in diameter); both are

thin enough to enter the small tumor-feeding arteries such as

small hepatic arteries.

Figure-2 Microscopic features of Embospheres (diameter,100-300 μm)

Embospheres, one of the microsphere particles are smooth-sur-

faced, spherical, and relatively uniform in size.

(Courtesy of Nihon Kayaku KK)

sometimes this becomes serious.

IVR-CT (Figure-3) can take CT images during

arterial infusion of contrast agents (CT during

angiography) which precisely show the distribu-

tion of each artery, and it helps with planning which

arteries should or should not be embolized. Some-

times there are multiple tumor-feeding arteries

with each artery feeding a different part of the

tumor, so that embolization of several arteries is

required. Newly developed angiography machines

called cone-beam CT can reconstruct the data to

show CT-like images; this is also useful for

determining the distribution of the tumor-feeding

arteries 11)-13).

Treatment of tumors with TACE

Theoretically, TACE can be performed for any

cancer; however, because of potential adverse

effects, application of this treatment should be

performed carefully. Microspheres are permanent

materials and cause embolization of non-target

organs such as gallbladder, pancreas, stomach,

duodenum, and other digestive organs if injected

into inappropriate arteries. Liver cancer, including

HCC and liver metastases, is one of the best lesions

to be treated by TACE because the hepatic double

blood supply (80% portal vein feeding and 20%

hepatic arterial feeding) means that non-target

embolization of hepatic arteries in normal liver

parenchyma does not induce serious problems. The

situation with lung cancer is nearly the same as that

with liver cancer because lung is perfused by both

bronchial arteries and pulmonary arteries. Other

solid tissues such as breast, kidney, lymph node, and

bone are also candidates for transarterial chemoem-

bolization. Even cancers of the stomach, colon, and

other digestive organs are candidates for this

therapy; however, careful selective injection to the

target lesions without non-target embolization is

required to avoid severe adverse events such as

perforation of the digestive organs and pancreatitis.

Two protocols for TACE with microspheres,

monthly and on demand, are commonly used. Once

TACE with microspheres is planned and per-

formed, the patient is discharged within 3 days after

the procedure and evaluated one month after the

procedure, followed by a second TACE with

microspheres. The therapy can be repeated on

demand after evaluation with CT. If the therapy is

not effective, the type of anti-cancer drugs will be

changed. Because the side effects to other parts of

the body, such as the bone marrow, skin, and

gastrointestinal tract, are minimal, patients receiv-

ing this therapy have a better quality of life than

those receiving systemic chemotherapy.

HCC and liver metastasis

The usefulness of hepatic arterial chemoemboli-

zation for HCC was first reported by Yamada et al.

in 1983 14). They performed TACE for unresectable

HCCs and observed that the 1-year survival rate

(44%) was much better than that of surgery (28%)

at that time. They used 1-2 mm pieces of gelatin

sponges embedded with 10 mg of mitomycin C or 20

mg of Adriamycin (doxorubicin hydrochloride) for

the therapy. They also performed embolization

therapy for various malignant tumors other than

HCC, such as lung cancer, renal cell carcinoma,

uterine cancer, and bladder cancer, and observed

that the best result was obtained with HCC. Also in

1983, Nakamura 15) reported a case of resected HCC

after TACE (Adriamycin infusion immediately

followed by gelatin infusion) and described that

good results were obtained for small, thickly-encap-

sulated lesions located at sites remote from

collateral circulation. In both reports, complications

such as gangrenous cholecystitis were severe due

to the wide distribution of embolization, including of

the cystic artery. Oily chemoembolization, reported

by Nakamura in 1989, which used a mixture of

dissolved doxorubicin and iodized oil (lipiodol)

Kuwatsuru, et al: Arterial chemoembolization for cancers

222

Figure-3 Angiography with computed tomography (CT)Angiography with CT allows CT to be performed during angio-

graphy at the same time.

followed by gelatin sponge particles, is the model for

the currently performed“conventional TACE

(cTACE)”16).“Segmental TACE”17),“subsegmental

TACE”18), and“ultraselective TACE”19) arterial

embolization, which have better therapeutic effects

and fewer complications than cTACE, have arisen

with the development of improved catheter techni-

que and the advent of micro-catheters. Patients

undergoing selective TACE have been shown to

have better survival rates than those subjected to

non-selective embolization 20). A prospective, sin-

gle-arm, controlled study of TACE for unresectable

HCC showed a good response rate of 73% (com-

plete response [CR], 42%; partial response [PR],

31%) and an excellent 2-year survival rate of

75% 21). Lipiodol is used as the liquid contrast agent

not only to embolize the tumor but also to embolize

the area surrounding the tumor and the portal vein

near the tumor where extratumoral invasion

frequently occurs (Figure-4). The therapeutic

effect is strong because the tumor and its surround-

ing area, which contains extracapsular invasions

and daughter nodules, are embolized simultane-

ously. Sponge particles are useful to retain the

lipiodol longer and to strengthen the anti-tumor

effect. The role of the choice of chemotherapeutic

drug in TACE is uncertain 22) 23), and is to be

confirmed in the future.

Microspheres are now used as the embolic agent

in both bland embolization (which uses embolic

agent only) and TACE with drug-eluting micro-

spheres (which uses embolic agent impregnated

with chemotherapeutic drugs such as doxorubicin

and epirubicin). In bland embolization, the main

treatment mechanism is the ischemic effect, which

induces a reduction in tumor size. Because HCC is

fed only by the hepatic artery, bland embolization

with microspheres is effective for unresectable

HCC due to the embolization of the tumor and small

tumor-feeding artery, and it causes less severe liver

and biliary damage than TACE7)-10) thereby

minimizing post-embolization syndrome. Bland

embolization tends to preserve the arterial patency

even after several repeat sessions 24). There have

been no reports comparing the efficacy of bland

embolization with that of cTACE. The efficacy of

TACE using drug-eluting beads (DEB-TACE)

seems superior to that of bland embolization with

microspheres 25) 26); however, liver damage is less

with bland embolization 26).

Comparison of the efficacy between cTACE and

DEB-TACE for HCC is controversial, and no

statistically significant differences have been

reported to date 27)-29). cTACE and microsphere

embolization can be beneficial for different applica-

tions. Microspheres can embolize the tumor and

tumor feeding arteries more tightly than can gelatin

sponge; however, because lipiodol is a liquid agent,

it reaches not only the tumor, but also the

peritumoral area and the nearby portal vein. Since

HCCs sometimes have satellite lesions and extra-

capsular invasion, accumulation and blockade of the

surrounding area of HCC by embolic agents such as

lipiodol has a superior tumor necrosis effect to other

embolic agents such as microspheres and gelatin

sponge particles. Bland embolization with micro-

spheres is an effective therapy for large hypervas-

cular HCCs, because stopping arterial flow will

cause necrosis of most of the tumor in these cases.

Small residual tumors which remained after first


223

A B

Figure-4 HCC before and after superselective TACEA.HCC (arrow) is well enhanced after bolus injection of contrast media.

B. After the superselective TACE, lipiodol accumulation is clearly visualized as white area in the tumor.

treatment by bland embolization, are treated in a

second session when the tumor is too large to treat

one session.

One good candidate for DEB-TACE might be

liver metastasis (Figure-5). Seki et al. reported the

case receiving the TACE with docetaxel-loaded

microspheres who had liver metastases from

colorectal cancer that were refractory to the

current systemic chemotherapy 30). After 3 courses

of TACE, tumor marker had decreased and PR was

obtained by RECIST criteria. Huppert et al.

performed a prospective study of TACE with

irinotecan-eluting microspheres for colorectal can-

cer liver metastases in a salvage setting and

showed this treatment to be safe but provided only

limited efficacy: the median time to progression

was 5 months and median overall survival after first

TACE was 8 months 31). Changing the drug and

decreasing the size of microspheres is being

considered to improve the effectiveness of this type

of treatment.

Lung cancer and pulmonary metastasis

Currently, the use of TACE for lung tumor

therapy has not been widely accepted due to the

lack of enough clinical experience. Bronchial artery

embolization is performed commonly for patients

with hemoptysis; it effectively improves symptoms

including bleeding from primary lung cancer and

pulmonary metastases and benign lesions 32) 33). Park

et al. reported the result of arterial embolization for

primary lung cancer patients with hemoptysis 32).

Though the technical success rate was 100%, and

the clinical success rate was 79%, the rate of

recurrence of hemoptysis was high (33%). For

malignant lesions, both stopping the bleeding and

shrinkage of the tumor by chemotherapy are

necessary to stop the hemoptysis without recur-

rence.

Bronchial arterial infusion (BAI) therapy is the

infusion of chemotherapeutic agents into the

bronchial artery and other associated systemic

arteries. This therapy was introduced about 50

years ago for advanced lung cancer patients who


224

Figure-5 Gastric cancer with liver metastasesThe huge liver metastasis (arrow) had rim enhancement on contrast-enhanced CT before TACE with docetaxel-loaded microspheres (A)

and became small with little enhancement 2 months after the initial TACE (B). Hepatic angiography showed perfusion of the tumor in the

right lobe of the liver before TACE (C) whereas there was almost no perfusion after TACE (D).

A B

CC DD

could not be treated with surgery, chemotherapy,

or radiation therapy, and it was reappraised as a

preoperative adjuvant therapy for advanced hilar

stage IIIA and IIIB lung cancer in 1990 1). In one

report, BAI with cis-diamminedichloroplatinum

had a PR rate of 67% for locally advanced non-small

cell lung cancer 2) and had a CR of 100% for centrally

located early-stage lung cancer 3). The advantage of

BAI therapy for lung cancer is that a high

concentration of chemotherapeutics reaches the

lesion even though the infusion dose is less than

systemic therapy; this means that the therapy can

be repeated many times, and the systemic and local

side effects are minimal.

The anatomy of bronchial arteries varies

between people 34) and lung cancer is fed not only by

bronchial arteries but also by systemic arteries

such as the internal thoracic artery, intercostal

artery, and lateral thoracic artery. Therefore,

detection of tumor-feeding arteries is important.

Nakanishi reported the usefulness of multi-arterial

infusion chemotherapy for patients with advanced

non-small cell lung cancer 35). In their study, 1 (3%)

CR and 16 (50%) PR were obtained with gemcita-

bine plus cisplatin as the first-line drug combina-

tion, with the exception that doxorubicin was used

instead of cisplatin in patients with renal dysfunc-

tion and anorexia. They found 1 to 10 (mean±SD,

3.8±2.0) feeding arteries for lung tumors, 0 to 1

(mean ± SD, 0.7 ± 0.1) for hilar lymph node

metastasis, and 0 to 2 (mean± SD, 0.8± 0.1) for

mediastinal lymph node metastasis. Stronger stain-

ing lung tumors and lymph node metastases by

angiography showed a marked response. As

mentioned above, we now can use CT during

angiography, allowing more precise evaluation of

tumor staining, and more distal catheter insertion is

possible to avoid normal tissue damage.

The use of TAE with microspheres for pulmo-

nary metastases from renal cell carcinoma has been

reported 36). The report showed the safety, local

efficacy, and palliative effects of bronchial artery

embolization with microspheres (superabsorbent

polymer microspheres, SAP-MS), a micro-cathe-

ter, and CTA. The total response rates (PR+CR) at

1, 3, and 6 months after therapy were 38.8%

(19/49), 44.9% (22/49), and 38.8% (19/49),

respectively. Highly-enhanced lesions showed a

high total response rate (90.9%) and 1-5 (median,

2.9) tumor-feeding arteries were successfully


225

Figure-6 Pulmonary cancer with mediastinal lymph node metastasesRight bronchial arteriography showed tumor perfusion in a mediastinal lymph node behind the superior vena cava (A), which was confirmed

by CT during angiography (B). Right internal thoracic arteriography showed tumor perfusion at the mediastinal lymph node ventral to the

superior vena cava (C) which was confirmed by CT during angiography (D). CT before TACE showed narrowing of the superior vena cava

(arrow; E) and narrowing improved due to the volume reduction of the mediastinal lymph nodes 3 months after TACE (F).

AA B CC

D E F

embolized. After each cannulation of the tumor-

feeding artery, CTA was performed and the

distribution of contrast medium was confirmed.

CTA, which is more accurate than angiography,

was required to check abnormal enhancement of

the spinal cord, left atria, and esophagus to avoid

spinal cord injury, non-target embolization, and

esophageal embolization. In our cases, some cases

showed good response rate with DEB-TACE

(Figure-6).

Conclusion

The advent of micro-catheters and micro-guide-

wires, CT angiography apparatus, and new embolic

materials such as microspheres has helped to make

TACE more effective and widely applicable for

human cancers.

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6) Lewis AL, Gonalez MV, Lloyd AW, et al: DC bead: invitro characterization of a drug-delivery device fortransarterial chemoembolization. J Vasc Interv Radiol,2006; 17: 335-342.

7) Covey AM, Maluccio MA, Schubert J, et al: Particleembolization of recurrent hepatocellular carcinoma afterhepatectomy. Cancer, 2006; 106: 2181-2189.

8) Osuga K, Hori S, Hiraishi K, et al: Bland embolization ofhepatocellular carcinoma using superabsorbent polymermicrospheres. Cardiovasc Intervent Radiol, 2008; 31:1108-1116.

9) Maluccio MA, Covey AM, Porat LB, et al: Trans-catherter arterial embolization with only particles forthe treatment of unresectable hepatocellular carcinoma.

J Vasc Interv Radiol, 2008; 19: 862-869.10) Bonomo G, Pedicini V, Monfardini L, et al: Bland

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227

Development of Endovascular Therapy for Intracranial Aneurysms

HIDENORI OISHI＊

＊Department of Neuroendovascular Therapy, Juntendo University Faculty of Medicine, Tokyo, Japan

Subarachnoid hemorrhage due to the rupture of intracranial aneurysms is one of the causes of life-threatening

strokes. The incidence is about 20 per 100,000 among the Japanese population. An intracranial aneurysm is a

bulging, weakened area in the wall of an artery in the brain, resulting in abnormal widening or ballooning. Because

the aneurysm has a weakened spot, there is a risk of rupture. Although surgical clipping has been the standard

treatment for intracranial aneurysms, the procedure is extremely invasive. Coiling is another recent endovascular

therapy that has become an important alternative to clipping because it is considerably less invasive. The

procedure uses a catheter percutaneously inserted into an artery under fluoroscopic imaging. When the

microcatheter has been inserted into the aneurysm, platinum coils are inserted to occupy the aneurysm cavity,

which prevents blood flow into the aneurysm. The simple technique, requiring only one microcatheter, without

other assisting devices, is standard. When this simple technique cannot achieve satisfactory occlusion, adjunctive

techniques using a balloon or stent are used. Coiling is more advantageous than surgical clipping because it does

not involve opening the skull, and hospitalization and recovery times are often shorter than with surgical clipping.

In the near future, the introduction of flow diverters may dramatically change the treatment outcome of large,

fusiform or complex aneurysms.

Key words: subarachnoid hemorrhage, intracranial aneurysm, endovascular therapy, coiling

Introduction

Subarachnoid hemorrhage (SAH) due to the rup-

ture of intracranial aneurysms is one of the causes

of life-threatening strokes. The annual incidence of

aneurysmal SAH is about 20 per one hundred

thousand in the Japanese population 1). An intracra-

nial aneurysm is a bulging, weakened area in the

wall of an artery in the brain, resulting in an

abnormal widening or ballooning. Because the

aneurysm has a weakened spot, there is a risk of

rupture. The overall prevalence of unruptured

intracranial aneurysms in the Japanese population

is reported to be about 3% and increasing with

age 2). Patients with ruptured aneurysms have to be

treated as soon as possible, preferably within 72

hours after the initial rupture to prevent possible

rebleeding. Patients with unruptured aneurysms

require accurate risk assessment of potential rup-

ture, death, or disability due to rupture and must be

informed of the risks related to various treatment

options.

228

Hidenori Oishi

Department of Neuroendovascular Therapy, Juntendo University Faculty of Medicine




〔Received Jan. 15, 2015〕

Figure-1 Illustration of coiling of an intracranial aneurysm



Surgical clipping has been the standard treat-

ment for intracranial aneurysms. However, less

invasive treatment is on demand because surgical

clipping is so invasive. Endovascular therapy has

significantly progressed from the first cerebral

angiography developed by the Portuguese neurolo-

gist, Egas Moniz, in 1927 3). The earliest endovascu-

lar therapy of aneurysms is attributed to Serbi-

nenko in 1969, which used detachable balloons to

occlude the aneurysm4). Since the introduction of

detachable coils by Guglielmi, the GDC®(Stryker

Neurovascular, Fremont, CA, USA), in 1991 5) 6),

coiling has become the first option and mainstay of

endovascular therapy for intracranial aneurysms

(Figure-1). Coiling was approved in Japan in 1997.

Indications

In the beginning, endovascular therapy was

favorably indicated for intracranial aneurysms with

surgical access difficulty (posterior circulation, the

paraclinoid region of the internal carotid artery),

patients with severe systemic comorbidities, and

elderly or high-grade SAH patients. In 2002, the

International Subarachnoid Aneurysm Trial (ISAT)

study group reported that endovascular therapy

showed more favorable results in survival free of

disability, 1 year after an aneurysmal SAH, than did

neurosurgical treatment for patients suitable for

either of the treatments 7). After the ISAT report,

endovascular therapy has become an important

alternative therapy for which the indications have

considerably widened. However, ruptured aneurysms

with massive intraparenchymal hematoma, aneur-

ysmswith voluminous intra-aneurysmal thrombus, or

aneurysms significantly compressing the optic

nerve/brain parenchyma should be excluded from the

indications. Three-dimensional (3D) computed tomo-

graphic angiography ormagnetic resonance angiogra-

phy could help physicians determine appropriate

indications for coiling, but catheter angiography is the

best modality to evaluate angioarchitecture most

accurately.

1. Development of angiographic suites

Endovascular procedures require clear digital

subtraction angiography (DSA) produced with the

fluoroscopy technique and contrast medium injec-

tion. Angiographic suites have developed from a

single-arm with a cathode ray to coupled image

intensifiers, to biplanes with flat-panel detectors

with enhanced resolution, and magnification (Fig-

ure-2), and have the capability of producing 3D-


229

Figure-2 Photograph of an angiographic suite

Figure-3 3D-digital subtraction angiography (DSA) ofaneurysm and surrounding vessels

Figure-4 Virtual stenting image

rotational angiograms (Figure-3), 3D-roadmap

capability, aneurysm metric analyses, and virtual

stenting ability (Figure-4).

Materials and methods

While local anesthesia is feasible, most patients

receive general anesthesia because of improved

image quality and safety for intraprocedural

aneurysm rupture. Patients receive systemic hepa-

rinization with an activated clotting time of greater

than 5 minutes throughout the procedure. An

antiplatelet medication is given several days before

the procedure and continued for at least 1 to 2

months after the procedure. The puncture site is

the femoral artery in most patients. When the

femoral artery is not available, the brachial or

carotid artery is alternatively used. A catheter (a

long, thin tube) is inserted into an artery from the

puncture site, and then advanced into the artery in

the brain under fluoroscopic images. When the

microcatheter has been inserted into the aneurysm,

coils are then inserted to occlude the aneurysm

cavity, which prevents blood flow into the aneur-

ysm. The coils are left in place permanently in the

aneurysm.

1. Catheters and guidewires

A guidingcatheter is a catheter that is typically

placed in the internal carotid artery or vertebral

artery and accommodates a microcatheter and

other devices. Preferably it is 6 French in caliber to

allow for guidingcatheter angiograms with a micro-

catheter or other devices in place. A soft tip

guidingcatheter is flexible, allowing for positioning

in the distal internal carotid or vertebral artery but

is less stable. A rigid tip guidingcatheter provides

an adequate platform but increases the risk of

vessel damage.

Microcatheters provide access to an aneurysm

and are available in various sizes and shapes.

Preshaped microcatheters are preferred. When

preshaped devices are unavailable, steam shaping

of the catheter tip is an option. Two-tipped micro-

catheters are necessary. The two tips in microcath-

eters are always 3 cm apart and can be used for

recognizing the coil detachment position. Com-

monly used microcatheters include the Excelsior

SL-10® (Stryker Neurovascular, Fremont, CA,

USA) and the Excelsior 1018®(Stryker Neurovas-

cular). The Excelsior 1018 can accommodate 10-

and 18-system coils.

Microguidewires are used to navigate the micro-

catheter to the target aneurysm under the road-

mapping image and provide other assistance.

Various microguidewires are available that differ in

size, degree of stiffness, visibility on fluoroscopy,

and have the ability to shape, steer, track, and

torque. Intermediate catheters are sized between a

guidingcatheter and a microcatheter and provide

stable access by functioning as a bridge between

the two catheters in a triaxial configuration of the

microguidewire and microcatheter, the intermedi-

ate catheter, and the guidingcatheter.

2. Coils

Currently, various platinum coils, differing in size,

shape, design, stiffness, and detachment system are

available (Figure-5A〜C). Coils consist of a fine

platinum thread looped around a thicker platinum

core that is connected to a pusher wire. The

detachment mechanisms are electrical, mechanical,

or hydraulic. Coil sizes have been traditionally

categorized into 10- and 18-system coils, a nomen-

Oishi: Endovascular therapy for intracranial aneurysms

230

Figure-5 Framing coils: A. 360˚ shape, B. 3D shape, C. helical shape

A B C

clature that originated with the introduction of the

first microcatheters used to deploy GDCs®. The

actual diameters of the 10- and 18-system coils are

0.008 and 0.016 inches, respectively. Although the

10-system is adequate for most aneurysms, the

18-system coils are preferred to frame larger,

wide-neck aneurysms. At present, there are

several coils on the market that have a larger diam-

eter while maintaining the comparable softness of

the 10-system.

Augmentations of platinum coils coated with poly-

glycolic polylactic acid (PGLA), theMatrixTM (Stryker

Neurovascular), and with hydrogel, the HydroCoil®

(MicroVention, Aliso Viejo, CA, USA), were devel-

oped to decrease the rate of aneurysm recanalization

(Figure-6A, B). They each have shown variable

degrees of efficacy8) -10).

Coiling techniques

1. The simple technique

The simple technique is the gold standard, for

which the appropriate aneurysm configurations are

a narrow neck and small in size. This technique

requires only one microcatheter without any other

assisting devices. After the guidingcatheter is

advanced into the cervical vessels, the microcath-

eter is inserted into the target aneurysm with the

assistance of a microguidewire. The appropriate

size and shape of coils are inserted into the

aneurysm until the aneurysm is satisfactorily

occluded (Figure-7A〜C). Coil insertion is carried

out by framing, filling, and finishing. Ideally, framing

coils extend across the neck to reduce the defective

neck area. Filling coils are helical or expanding 3D

and are intended to completely fill the aneurysms

without compartmentalization. Finishing coils are

the softest and are designed to finally pack the

aneurysm. Coil insertion is done as tightly as

possible, which is the best way to prevent recanali-

zation and regrowth of the aneurysm. The packing

density should be more than 20% 11).

2. The adjunctive technique

Despite advances in coil shape technology, aneur-

ysms with unfavorable morphology (wide neck, low

dome-to-neck ratio) present the risk of coil herniation


231

Figure-6 Augmentations of platinum coils: A. A PGLA-coated coil, B. A hydrogel-coated coil

AA

BB

Figure-7 Aneurysm occlusion: (A) pretreatment (B) post-treatment DSA image, (C) native image

AA BB CC

into the parent artery. Therefore, physicians tend to

be less aggressive about achieving high packing

densities, leading to higher rates of incomplete

occlusions, increased neck remnants, and more

recurrence over time. To address these problems, the

adjunctive techniques of balloon- and stent-assisted

techniques have been developed.

1) The balloon-assisted technique (Figure-8)

A microcatheter capable of delivering coils is

positioned inside the aneurysm, and a balloon is

then inflated in the parent artery across the neck of

the aneurysm, stabilizing the catheter and allowing

coil delivery without herniation into the parent

artery 12) 13). HyperGlideTM, HyperFormTM (Micro

Therapeutics, Irvine, CA, USA), and TransFormTM

(Stryker Neurovascular), these are all single-

lumen balloons that can be used for this pur-

pose 14) 15). The balloon will inflate after an appropri-

ately sized wire is advanced past the catheter tip,

which seals the catheter. The Scepter® (Terumo

Corporation, Tokyo) has a double-lumen balloon

that allows exchanging microguidewires 16) 17). A

few risks of using a balloon include aneurysmal

rupture during inflation and arterial injury due to

over inflation.

2) The stent-assisted technique (Figure-9)

Commercially available stents in Japan are the

open-cell Neuroform EZ®(Stryker Neurovascular)

and the closed-cell design, EnterpriseTM(Codman,

Raynham, MA, USA) 18) 19). In the closed-cell design,

all of the stent struts are connected, and the stent

moves as a single piece, with the pores fixed and

closed (Figure-10A). In the open-cell design, about

half of the struts are not connected, allowing some

of the pores to be open (Figure-10B). These pro-

perties may affect the stent apposition to the wall of

the artery. Generally, the open-cell stents are often

used in more tortuous artery segments. The goal of

stent delivery is to cover the aneurysm neck and to

provide structural support to keep the coils inside

the aneurysm. The stents may also provide a

hemodynamic benefit and may also serve as a

scaffold for endothelialization 18) 19).

There are two techniques in stent-assisted

coiling: trans-cell and jailing. In the trans-cell

technique, the stent is delivered followed by passing

the microcatheter for coiling through the stent. In

the jailing technique, the stent is delivered after the

placement of the microcatheter to aide in coiling

into the aneurysm. In order to prevent thromboem-


232

Figure-8 Illustration of balloon-assisted coiling Figure-9 Illustration of stent-assisted coiling

Figure-10 Commercially available stents in Japan: A. open-cell stent, B. closed-cell stent

AA BB

bolic complications related to the stents, patients

have to be given dual antiplatelet medication

initiated at least 7 days prior to the procedure and

continuing until at least 6 months after.

Treatment results and complications

Although the operation times from puncture to

removal of guidingcatheter are variable depending

on the technique used and characteristics of the

aneurysms, the average time is about 1-2 hours.

Patients with unruptured aneurysms may be

hospitalized up to 1 week but may return to work in

about 2 weeks unless otherwise instructed by their

physicians. Most patients treated with coils for an

unruptured aneurysm can expect to live normal

and productive lives. Patients treated with coils for

a ruptured aneurysm face challenges ranging from

minor to serious, depending on the severity of the

rupture. Short-term memory loss and headaches

are common after a ruptured aneurysm. Some of

these deficits may disappear over time with healing

and therapy.

Aneurysm recurrence after coiling occurs in

about 30% of patients 7) 20). Recurrence happens if

coils do not completely block off the aneurysm or if

the coils become compacted within the aneurysm. A

recurrence may not be significant enough to

require additional treatment. If a major portion of

the aneurysm remains unfilled, additional coiling or

surgical clipping can be placed to stop the growth.

All patients with coiled aneurysms are advised to

undergo magnetic resonance angiography (MRA)

6 months after and catheter angiography 1 year

after the procedure to monitor for a residual or

recurring aneurysm. Further follow-up MRAs are

then performed yearly depending on the presence

of an aneurysm remnant.

No procedure is without risk. General complications

related to surgical clipping include infection, allergic

reactions to anesthesia, stroke, seizure, and bleeding.

Complications specifically related to coiling include

thromboembolism and intraprocedural aneurysm

rupture. Thromboembolisms occur in 8% of cases, but

stroke only occurs in 3%. Intraprocedural aneurysm

rupture may be caused by puncture of the aneurysm

with the microcatheter, guidewire, or the coils. This

occurs in about 2% of ruptured aneurysm cases that

already have a weakened wall 21).

Discussion

1. Flow diverters

The endovascular treatment paradigms for intra-

cranial aneurysms can be divided into reconstruc-

tive strategies (aneurysm occlusion with parent

artery preservation), previously mentioned, and

deconstructive strategies (parent artery occlu-

sion), with or without revascularization. Because

reconstructive strategies are frequently not feasible

for large, fusiform or complex aneurysms, decon-

structive strategies are required. The introduction

of flow diverters may dramatically change the

treatment outcome of those aneurysms in the near

future (Figure-11). The flow diverter placement in

front of the aneurysm neck causes flow stagnation

within the aneurysm due to the flow diversion

function, which leads to thrombosis of the aneur-

ysm, with flow preservation through the parent

vessels and their branches. There are, as yet, no

commercially available flow diverters in Japan.

Despite the recent experience with flow diverters

reported in other countries, the surmounting

current data suggest that this technology is an

effective therapeutic option, even though the risks

associated with these procedures using these novel

devices are not negligible 22-25).

Endovascular therapy for intracranial aneurysms

has become an important option to surgical clipping.

With the ever-increasing experience and beneficial

prognostic evidence, along with the technological

development of the requisite devices, the indica-

tions have considerably widened, and the safety and


233

Figure-11 Illustration of a flow diverter for an intracranialaneurysm

efficacy of endovascular therapy for the treatment

of intracranial aneurysms have improved signifi-

cantly.

Acknowledgement

We thank Robert E. Brandt, Founder, CEO, and

CME, of MedEd Japan, for editing and preparing

the manuscript.

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234

Endovascular Treatment for Ischemic Stroke

MUNETAKA YAMAMOTO＊, HIDENORI OISHI＊, HAJIME ARAI＊

＊Department of Neurosurgery, Juntendo University Faculty of Medicine, Tokyo, Japan

In Japan, out of the total number of deaths classified by cause in 2013, 120,000 deaths were due to strokes,

making up 9.3% of the total and putting stroke in 4th position. On the other hand, strokes are the number one

cause that requires long-term nursing care and comprise 20% of the total. Strokes are broadly classified into

cerebral infarctions, intracerebral hemorrhages, and subarachnoid hemorrhages. A cerebral infarction is caused

by the occlusion of a blood vessel in the brain. The most important form of treatment for cerebral infarction is

prevention. The purpose of performing recanalization therapy for acute ischemic stroke, in which the occluded

vessel has reopened, is minimizing the extent of possible cerebral infarction. Intravenous administration of

thrombolytic drugs to treat acute ischemic stroke within three hours of onset started being performed in Japan in

2005. In 2010, a spiral-shaped device, Merci Retrieval System, became available for use in Japan for thrombi

retrieval and heralded the era of mechanical thrombectomy. In 2011, a thrombus aspiration device that used a

catheter, Penumbra System, was introduced. In 2014, stent thrombectomy devices, Solitaire Flow Restoration

device and Trevo ProVue Retriever, were successively introduced, which allowed for a full range of treatment

selections for full-scale endovascular treatment for acute ischemic stroke.

Key words: ischemic stroke, cerebral infarction, mechanical thrombectomy, endovascular treatment

Introduction

The mortality rate for strokes in Japan has been

reduced due to treatment of hypertension and an

increase in the standard of treatment. According to

the Summary of Vital Statistics (Ministry of Health,

Labour and Welfare (MHLW) ), out of the total

number of deaths classified by cause in 2013,

120,000 deaths were due to strokes, making up

9.3% of the total and putting stroke in 4th position.

On the other hand, according to the Summary of the

Comprehensive Survey of Living Conditions

(MHLW), strokes are the number one cause that

requires long-term nursing care and comprise 20%

of the total. According to the Summary of the

Patient Survey (MHLW), the number of stroke

patients is over 1.3 million and strokes occur in

300,000 individuals annually. The rate of stroke

onset per 100,000 members of the population

during the past decade was approximately 1,000,

indicating that although the mortality rate has

decreased, prevalence has hardly decreased. The

breakdown for strokes has not been revealed in the

national statistics, but when calculated based on a

report from the Hisayama Study 1), 65% were

cerebral infarctions, 25% were intracerebral hemor-

rhages, and 10% were subarachnoid hemorrhages.

The number of stroke patients whose lives are

saved but who are left with severe sequelae is

increasing.

Cerebral infarction

A cerebral infarction is caused by the occlusion of

a blood vessel in the brain. Cerebral infarction

occurs in 200,000 people annually, and in terms of

the prognosis in the 5 years after onset, the

mortality rate is 40%, 20% of patients require

long-term care including bedridden patients and

the condition improves in 40% of patients. The

235

Corresponding author: Munetaka Yamamoto

Department of Neurosurgery, Juntendo University Faculty of Medicine

2-1-1 Hongo, Bunkyo-ku,Tokyo 113-8421, Japan

TEL: +81-3-3813-3111 (ext. 71011) E-mail: [email protected]


〔Received Feb. 28, 2015〕



mechanism of blood vessel occlusion is classified

into 3 types.

1. Lacunar infarction

Lacunar infarcts occur when the arterioles that

supply blood to the deep parts of the brain paren-

chyma are affected by hypertension and develop

atherosclerosis, leading to occlusion. These infarctions,

which comprise about 30% of all cerebral infarctions,

are on the decline, with advances in the treatment of

hypertension.

2. Atherothrombotic cerebral infarction

Atherothrombotic cerebral infarctions are caused

by vascular atherosclerosis (plaque). Atherosclero-

sis is caused by damage to the vascular intima,

which causes the infiltration of leukocytes and

accumulation of lipid components into the arterial

wall. Furthermore, vascular smooth muscle cells

migrate into the vascular intima and proliferate.

This results in the formation of plaque when the

deposition of fibrous components and lipids coat the

internal intimal surface. Risk factors include hyper-

tension, diabetes mellitus, dyslipidemia, and smok-

ing. Intraluminal occlusion is caused by plaque

enlargement and rupture and dispersion of the

ruptured plaque or the thrombus that has formed

results in occlusion of the peripheral cerebral blood

vessels, resulting in cerebral infarction. Thirty

percent of all cerebral infarctions are atherothrom-

botic cerebral infarctions.

3. Cardioembolic stroke

Cardioembolic strokes are caused by emboli that

originate in the heart and occlude the flow of blood

to cerebral blood vessels; they comprise 28% of all

strokes. The most common condition that causes

emboli to form in the heart is an arrhythmia known

as atrial fibrillation. The sudden occlusion near the

center of the previously normal blood vessel means

that no collateral circulation develops and because

the resulting strokes are usually extensive, they

tend to be serious. There are said to be 1,000,000

patients with atrial fibrillation, and in recent years,

the frequency of cardioembolic stroke onset has

been increasing.

Treatment of cerebral infarctions

1. Primary prevention

The most important form of treatment for

cerebral infarction is prevention. Primary preven-

tion includes drug treatment of hypertension,

diabetes mellitus, dyslipidemia, and arrhythmia, as

well as the improvement of lifestyle habits, such as

dietary therapy, exercise therapy, quitting smok-

ing, or avoiding alcohol consumption. In addition,

stenosis of the internal carotid artery in the neck

due to atheroma (internal carotid artery stenosis)

is an indication for surgical treatment (carotid

endarterectomy or carotid artery stenting), if

severe stenosis is present.

2. Secondary prevention

Secondary prevention is the prevention of recur-

rence. As a rule, treatment similar to that used for

primary prevention is selected, but there is stricter

monitoring and the expansion of the indications for

surgical treatment or endovascular treatment is

being investigated. In addition to surgical treatment

for carotid artery stenosis, cerebrovascular bypass

surgery and endovascular treatment (percutane-

ous transluminal angioplasty) are sometimes also

used to treat vascular occlusion of the intra- and

extra-cranial vessels, and intracranial vessel steno-

sis. The preventive effects of surgical treatment

have only been verified in combination with

sufficient internal medical therapy. Furthermore,

there are strict standards for the cerebrovascular

conditions that are eligible for surgical treatment so

sufficient care must be taken with determining

whether a case is eligible.

Recanalization therapy for acute ischemic stroke

The purpose of performing recanalization ther-

apy for acute ischemic stroke, in which the occluded

vessel has reopened, is minimizing the extent of

possible cerebral infarction. This is a completely

different concept to the treatment used to date for

primary and secondary prevention. This can be

achieved by either advancing a catheter into the

occluded blood vessel and performing thrombolysis

through the injection of thrombolytic drugs or

using a balloon catheter to physically widen the

occluded lesion. However, as these techniques are

Yamamoto, et al: Endovascular treatment for ischemic stroke

236

complex and their effects are insufficient, they have

not come into widespread use.

Intravenous administration of thrombolytic drugs

to treat acute ischemic stroke within three hours of

onset started being performed in Japan in 2005.

There is a drug known as Alteplase, which is a

recombinant tissue plasminogen activator (rt-PA) ;

treatment with this drug can be performed at

several institutions because it can be administered

through normal intravenous infusion. In 2012, the

administration criteria were expanded to include any

patient within 4.5 hours of stroke onset. When

administering thrombolytic drugs, the most frequent

complication is hemorrhage. This could involve a

cerebral hemorrhage caused by reperfusion of blood

into the area affected by cerebral infarction or a

hemorrhage at the location of extracranial systemic

pathology (gastric ulcer or aortic vascular dissec-

tion), and there could be hemorrhage at both sites. In

all cases, once hemorrhage has occurred, the effects

of the thrombolytic drug are catastrophic and it is

difficult to achieve hemostasis, meaning that these

cases are often severe. Therefore, the administration

criteria for this drug include various strict conditions

in addition to the time from onset. Reports indicate

that in clinical practice, administration of thrombo-

lytic drugs is only possible for 4%-5% of patients who

have suffered a cerebral infarction. In addition,

improvement of symptoms is obtained in 10% of

cerebral infarction patients treated with these

drugs 2). Furthermore, it is now known that if

occlusion occurs in the carotid vessels or in the main

intracranial arteries, known as the thick vessels,

achieving recanalization using thrombolytic drugs is

likely to be difficult.

Mechanical thrombectomy

In 2010, a spiral-shaped device, Merci Retrieval

System (Stryker Neurovascular, Fremont, CA, USA)

(Figure-1), became available for use in Japan for

thrombi retrieval and heralded the era of mechanical

thrombectomy. Thereafter, in 2011, a thrombus

aspiration device that used a catheter, Penumbra

System (Penumbra, Alameda, CA, USA) (Figure-2),

was introduced. In 2014, stent thrombectomy devices,

Solitaire Flow Restoration device (Covidien, Dublin,

Ireland) (Figure-3) and Trevo ProVue Retriever

(Stryker Neurovascular, Fremont, CA, USA) (Fig-

ure-4), were successively introduced, which allowed

for a full range of treatment selections for full-scale

endovascular treatment for acute ischemic stroke.

Reports of the efficacy of stent thrombectomy

devices in particular have come from the US and

Europe as the result of randomized controlled trials

(RCT) focusing on the Merci, which was developed

first (SWIFT3), TREVO 24)), and prospective

single-group trials (STAR5)), with high expecta-

tions centered on their introduction. Meanwhile,

results of 3 RCTs reported in 2013 (IMS-III 6),

SYNTHESIS Expansion 7), MR RESCUE8)) that

compared IV rt-PA monotherapy to use in combina-

tion with endovascular treatment were not able to

show efficacy in all cases that used rt-PA in

combination with endovascular treatment, and the

significance of endovascular treatment when treat-

ing acute ischemic stroke was called into question.

However, when these RCT findings were analyzed in

detail, results actually revealed an effective means of

endovascular treatment rather than denying the

significance of this treatment. In addition, the results

of an RCT from the Netherlands reported in 2014

(MR CLEAN9)) indicated favorable outcomes for


237

Figure-1 Merci Retrieval System (Stryker Neurovascular, Fremont, CA, USA)

combination with endovascular treatment. Thus,

recanalization via endovascular treatment almost

stopped being performed; however, is now once

again being promoted.

Conditions increasing

the outcomes of endovascular treatment

Clinical outcomes for recanalization by endo-

vascular treatment for acute ischemic stroke were

different in each RCT mainly because of the rate of

recanalization and the time until recanalization.

1. IMS-III

The rate of recanalization in the IMS-III was

clearly low at 23%-44%. This appears to be the

reason why stent devices with a high rate of

recanalization are currently not used. In other

words, because the data is based on techniques

before new devices were released onto the market,

it should not be used to rule out the efficacy of

current new devices. In addition, the time from

onset to recanalization was 317.5 min, which is

more than 60 minutes longer than the STAR, which

will be mentioned later.

The recanalization rate in MR RESCUE is 67%,

which appears high, but the definition of recanaliza-

tion is a problematic point. Compared to groups

where sufficient recanalization was achieved,

groups in which a sufficient extent of recanalization

was not achieved had unfavorable clinical outcomes,

as was previously shown in the aforementioned

IMS-III. The low value of the effective recanaliza-

tion rate may have caused the unfavorable clinical

outcomes. There was no mention of the time from

onset to recanalization, but the time from onset until

the angiography was started was 360 minutes or

more, demonstrating that the time up to recanaliza-

tion was quite a bit longer than in IMS-III.

2. STAR

The data in STAR was obtained using a stent


238

Figure-3 Solitaire Flow Restoration device (Covidien, Dublin,Ireland)

Figure-4 Trevo ProVue Retriever (Stryker Neurovascu-lar, Fremont, CA, USA)

Figure-2 Penumbra System (Penumbra, Alameda, CA, USA)

device, Solitaire FR. The effective recanalization

rate was high at 79.2%. In addition, the time from

onset to recanalization was 256 minutes, which was

shorter than in the other reports. During a

subanalysis, for each one hour that the time from

onset to recanalization was prolonged, the percent-

age of patients with a good clinical outcome

decreased by 38%, and irrespective of the rate of

recanalization, the time to recanalization was again

verified to greatly influence the clinical outcome.

3. MR CLEAN

An RCT study comparing IV rt-PA monotherapy

and concomitant use of endovascular treatment was

conducted at an institution in the Netherlands. The

device used for endovascular treatment was a stent in

97% of cases, and the time from onset to recanalization

was 360 min, with an effective recanalization rate of

58.7%. The clinical outcomes in the concomitant

endovascular treatment group were also favorable.

4. ESCAPE/EXTEND-IA/SWIFT-PRIME study

During the International Stroke Conference 2015,

the results of three RCTs were reported. Usefulness

for all endovascular treatments when using any of

the stent devices was reported.

The clinical outcomes after 90 days were favorable:

in the ESCAPE trial, 53% in the concomitant endo-

vascular treatment group and 29% in the monother-

apy group; in the EXTEND-IA trial, 71% in the

concomitant endovascular treatment group and 40%

in the monotherapy group; and in the SWIFT PRIME

trial, 60.2% in the concomitant endovascular treat-

ment group and 35.5% in the monotherapy group. In

all groups, the outcomes in the concomitant endovas-

cular treatment groups were better. Details from

forthcoming papers are awaited.

Thrombectomy device

1. Merci Retrieval System (Stryker Neurovascu-

lar, Fremont, CA, USA)

In 2004, approval was obtained from the Ameri-

can FDA for the first thrombectomy device. This

device is made up of a spiral-shaped coil and a

filament that are advanced to the distal end of the

thrombus, entangled in the thrombus, and then

used to pull it out. It was the first thrombectomy

device introduced in Japan in 2010. With the

commercialization of new devices with a high rate

of thrombectomy, it is no longer used, but it was a

ground-breaking device that allowed us to switch

from the local thrombolysis that had been per-

formed to date to a new method of treatment

known as mechanical thrombectomy.

2. Penumbra System (Penumbra, Alameda, CA,

USA)

Approved by the FDA in 2008 and introduced in

Japan in 2011, this device is used for aspiration and

removal of thrombi. It is made up of a reperfusion

catheter for aspiration, and an attached aspiration

pump, as well as a separator to prevent occlusion of

the inside of the catheter. The device is being

continuously improved and has evolved into a

device with a wider catheter that is better for

aspiration. Currently, the thrombus is aspirated

without using the separator and the ADAPT

technique 10), which involves the thrombus being

wedged onto the tip of the catheter and aspirated, is

the most popular.

If there is occlusion of the anterior cerebral

artery, middle cerebral artery, or the intracranial

internal carotid artery, a guiding catheter with an

attached balloon is inserted and placed. If the

occlusion starts from the origin of the internal

carotid artery, the device is placed in the common

carotid artery. If there is occlusion in the vertebro-

basilar arterial system, a guiding catheter is

inserted and placed into the vertebral artery;

however, if the vertebral artery is occluded, it is

usually difficult to insert a guiding catheter with

attached balloon. In such cases, a normal guiding

catheter with the maximum diameter that can be

inserted is selected. A reperfusion catheter with the

maximum diameter suitable for the occlusion

diameter is advanced to just before the occluded

region, and aspiration with the pump is attempted

for 90 s. If aspiration is unsuccessful, we employ the

ADAPT technique. The balloon on the guiding

catheter is proximally clamped, and the reperfusion

catheter is slowly withdrawn while continuing to

aspirate using the pump. In this case, it is more

effective to concomitantly use manual aspiration

with a syringe from the guiding catheter.


239

3. Solitaire Flow Restoration device (Covidien,

Dublin, Ireland)

This is a stent thrombectomy device approved by

the FDA in 2012 and introduced in Japan in July

2014. The device is made up of a single-sheet,

self-expandable stent designed in a cylindrical

shape. The stent was designed to capture the

thrombus, and the thrombus is interlocked while

the sheet that makes up the stent maintains its

overlapping structure. This device demonstrates an

extremely high ability to capture thrombi. The

stent itself cannot be confirmed radiographically,

and only the markers at either end are radiopaque.

4. Trevo ProVue Retriever (Stryker Neurovascu-

lar, Fremont, CA, USA)

This is a stent thrombectomy device approved by

the FDA in 2012 and introduced in Japan in July

2014. This is a self-expandable stent with vertical

struts directed perpendicular to the vessel wall.

When the central portion, which has the ability to

effectively capture thrombi, is advanced into the

site where the thrombus is located, the struts,

which are unique structures, become entangled in

the thrombus and grip tightly. Because the overall

stent of the Trevo, unlike the Solitaire, is radiopa-

que, it offers the advantage of clearly showing the

positional relationships between the stent and

thrombus.

Irrespective of which stent thrombectomy device

is used, the thrombectomy rate is currently at its

highest, with extremely high recanalization rate

and good clinical outcomes have been reported 3)-5).

The selection of the guiding catheter is similar to

that of the Penumbra system. After advancing the

microcatheter to a point distal to the occlusion site,

we use an image of both the microcatheter and

guiding catheter to gain an initial understanding of

the site of occlusion. The part of the stent that is

effective at grasping thrombi is extended into the

occlusion. In most cases, temporary recanalization

of the site of occlusion is confirmed immediately

after the stent is advanced. At this point in time, the

thrombus is pressing on and distorting the outside

of the stent and is not properly grasped. We wait for

a few minutes, and then confirm that the stent is

placed within the occlusion, at which time it is

determined that the stent has grasped the throm-

bus. The guiding catheter balloon is dilated, and the

proximal end is clamped, while blood is simultane-

ously aspirated from the guiding catheter during

stent retrieval. Immediately after the stent is

withdrawn from the body, the guiding catheter is

sufficiently aspirated and care is taken to ensure

that no thrombus remains inside the guiding

catheter 11).

Personal experience

Even in our experience, there has been an

obvious increase in recanalization rates through the

commercialization of stent thrombectomy devices

and improvement of the Penumbra system. Eight-

een acute ischemic stroke cases were treated under

mechanical thrombectomy in Juntendo University

Hospital from December 2011 to January 2015. Five

cases were treated by Merci Retrieval System

(TICI 12) 2b; 2 cases, TICI 0; 3 cases), 5 cases by

Penumbra System (TICI 3; 2 cases, TICI 2b; 3

cases), 5 cases by Trevo ProVue Retriever (TICI 3;

2 cases, TICI 2b; 2 cases, TICI 0; 1 cases), 3 cases

by Solitaire Flow Restoration device (TICI 3; 1

cases, TICI 2b; 2 cases). As a result, although we

have experienced cases in which symptoms have

improved dramatically, there are also cases in

which achieving recanalization is not associated

with an improvement in clinical symptoms. In

addition, even if recanalization is achieved within 3

hours of onset, there are also cases that we have

treated who experience no improvement in clinical

symptoms.

Conclusions

To make various techniques for shortening time

until recanalization possible, improvements to

surgeon skill supported by advances in devices are

necessary. Moreover, infrastructure for rapid

emergency treatment for each facility and the

cooperation of each related department are also

vital. The rapid progression of endovascular inter-

vention to treat acute cerebral infarction is likely to

have a major influence on the establishment of

regional cooperation for stroke treatment in the

acute phase.


240

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2) Tanahashi N: Thrombolysis by intravenous tissueplasminogen activator (t-PA)--current status andfuture direction. Brain Nerve, 2009; 61: 41-52.

3) Sever JL, Jahan R, et al, for the SWIFT Trialists: Solitaireflow restoration devices versus the Merci retriever inpatients with acute ischemic stroke (SWIFT) : a random-ized, parallel-grope, non-inferiority trial. Lancet, 2012; 380:1241-1249.

4) Nogueira RG, Lutsep HL, et al, for the TREVO 2 Trialists:Trevo versus Merci retrievers for thrombectomyrevascularization of large vessel occlusion in acuteischemic stroke (TREVO 2) : a randomized trial. Lan-cet, 2012; 380: 1231-1240.

5) Pereira VM, Gralla J, Davalos A, et al: Prospective,multicenter, single-arm study of mechanical thrombec-tomy using Solitaire Flow Restoration in acute ischemicstroke (STAR). Stroke, 2013; 44: 2802-2807.

6) Broderick JP, Palesch YY, et al, for InterventionalManagement of Stroke (IMS) III Investigators: Endo-

vascular therapy after intravenous t-PA versus t-PAalone for stroke. N Engle J Med, 2013; 368: 893-903.

7) Ciccone A, Valvassori L, et al, for SYNTHESIS Expan-sion Investigators: Endovascular treatment for acuteischemic stroke. N Engle J Med, 2013; 368: 904-913.

8) Kidwell CS, Jahan R, et al, for the MR RESCUE Inves-tigators: A trial of imaging selection and endovasculartreatment for ischemic stroke. N Engle J Med, 2013; 368:914-923.

9) Berkhemer OA, Fransen PSS, et al, for the MR CLEANInvestigators: A randomized trial of intraarterial treat-ment for acute ischemic stroke. N Engle J Med, 2015; 1:11-20.

10) Turk AS, Spiotta A, Frei D, et al: Initial clinicalexperience with ADAPT technique: A direct aspirationfirst pass technique for stroke thrombectomy. J Neuroin-terv Surg, 2014; 6: 231-237.

11) Nguyen TN, Malisch T, Castonguay AC, et al: Balloonguide catheter improves revascularization and clinicaloutcomes with the Solitaire device: Analysis of theNorth American Solitaire acute stroke registry. Stroke,2014; 45: 141-145.

12) Higashida RT, Furlan AJ, Roberts H, et al: Trial designand reporting standards for intra-arterial cerebralthrombolysis for acute ischemic stroke. Stroke, 2003; 34:e109-137.


241

Endovascular Treatment of Gastrointestinal Bleeding

AKIHIKO SHIRAISHI＊

＊Department of Radiology, Juntendo University Faculty of Medicine, Tokyo, Japan

Acute gastrointestinal (GI) bleeding is a common medical emergency that varies from minor to potentially

life-threatening bleeding. Endoscopy is a first-line diagnostic procedure for both upper and lower GI bleeding.

Therapeutic options for the treatment of acute GI bleeding include conservative management, therapeutic

endoscopy, transcatheter embolization, and surgery. Transcatheter embolization and surgery are both options for

recurrent GI bleeding when therapeutic endoscopy fails; however, both options are associated with several

complications and the risk of rebleeding. The choice of management depends upon the status of the patient.

Emergency surgery is typically associated with high rates of morbidity and death. Recently, superselective

transcatheter embolization has become a safer procedure and is now widely used for the management of acute GI

bleeding. This review article describes the role of interventional radiology in the management of acute GI bleeding.

Key words: endovascular treatment, transarterial embolization, GI bleeding

Introduction

Acute gastrointestinal (GI) bleeding is a common

medical emergency that varies fromminor, self-lim-

ited bleeding to potentially life-threatening bleed-

ing 1). The bleeding site can be located anywhere

along the GI tract, making determination of its

precise location challenging. Patients with upper GI

bleeding usually present with hematemesis or

melena and the bleeding point is proximal to the

ligament of Treitz, whereas those with lower GI

bleeding usually present with melena or hemato-

chezia and the bleeding point is distal to the

ligament of Treitz. Endoscopy is a first-line diag-

nostic procedure with 100% sensitivity for diagnos-

ing upper GI bleeding; however, it has only 60%

sensitivity for diagnosing lower GI bleeding. Thera-

peutic options for the treatment of acute GI

bleeding include conservative management, thera-

peutic endoscopy, transcatheter embolization, and

surgery 2) 3). Transcatheter embolization and sur-

gery are both options for recurrent GI bleeding

when therapeutic endoscopy fails; however, both

options are associated with several complications

and the risk of rebleeding. The choice of manage-

ment depends upon the status of the patient (e.g.,

the degree of hemodynamic instability or hypo-

tension, or whether there is a need for resuscita-

tion). Emergency surgery is typically associated

with high rates of morbidity and death 4)-6). How-

ever, recent technical improvements in superselec-

tive transcatheter embolization have increased the

procedureʼs safety and it is now widely used for the

management of acute GI bleeding 7). This review

article describes role of interventional radiology in

the emergent management of acute GI bleeding.

Upper GI bleeding

Upper GI bleeding is defined as bleeding originat-

ing from the distal esophagus, the stomach, or the

duodenum (i.e., proximal to the ligament of Treitz).

The most common cause of upper GI bleeding is

peptic ulcer disease, but the differential diagnosis is

diverse and includes benign and malignant tumors,

ischemia, gastritis, arteriovenous malformations,

242

Akihiko Shiraishi

Department of Radiology, Juntendo University Faculty of Medicine




〔Received Mar. 17, 2015〕



Mallory-Weiss tears, trauma such as Dieulafoyʼs

lesion, and iatrogenic causes.

Upper GI bleeding is a potentially fatal condition,

so immediate management and accurate diagnosis

of both the location and etiology of the bleed is

necessary. The primary diagnostic procedure for

upper GI bleeding is endoscopy, which has high

sensitivity and specificity for locating and identify-

ing bleeding lesions in the upper GI tract. Once a

bleeding lesion has been identified, therapeutic

endoscopy techniques such as thermal coagulation

or hemoclip placement can be used to achieve acute

hemostasis.

Endoscopic management achieves hemostasis in

the majority of patients, but 10% to 30% of patients

experience rebleeding, for a variety of reasons 8) 9).

When hemostasis is not achieved with endoscopic

management, other options include surgery and

transarterial embolization. Surgery has long been

the standard of care, but with the development of

interventional radiology, an increasing number of

patients are now referred for embolotherapy 10).

Transarterial embolization may prevent unneces-

sary resection of the upper GI tract and should be

considered as an alternative to surgery.

Lower GI bleeding

Lower GI bleeding is defined as bleeding originat-

ing from a source distal to the ligament of Treitz.

Approximately 80% of all lower GI bleeding comes

from a colorectal source and 5% to 10% from a small

bowel source; 10% to 15% is classed as blood of

upper GI tract origin. The source of small bowel

bleeding is more likely than that of colorectal

bleeding to be obscure or occult 11) 12). The most

common cause of lower GI bleeding is colonic

diverticula. The differential diagnosis includes

colitis or enteritis, anorectal anomalies (hemor-

rhoids, proctitis), tumors, arteriovenous malforma-

tion or angiodysplasia, and post-polypectomy

bleeding.

Therapeutic colonoscopy is currently a first-line

intervention for colonic bleeding. Colonoscopy is the

diagnostic modality of choice in patients with lower

GI bleeding, but therapeutic endoscopy may also be

successful in a limited number of patients 13)-17).

Therapeutic colonoscopy fails in approximately

32% of cases because of the presence of stool or

blood clots, or because of technical difficulties such

as the time required to prepare patients 18). Further

disadvantages include the fact that small bowel

bleeding cannot be accessed via colonoscopy 19) and

that colonoscopy is relatively ineffective when

performed without bowel preparation in patients

with marked bleeding 20) 21).

If the bleeding cannot be stopped with therapeu-

tic colonoscopy, transarterial embolization is the

next line of therapy for controlling hemostasis. As

with upper GI bleeding, transarterial embolization

is now a first-line therapy for patients with severe

lower GI bleeding 22). The efficacy of transarterial

embolization in treating acute GI bleeding when

medical or endoscopic techniques are insufficient

has been shown in several large studies 23) 24). In both

upper and lower GI bleeding, surgery is now

typically reserved as a last-line treatment for

patients whose bleeding has failed to respond to

previous treatments.

Angiography and embolization

In angiography, access to the blood vessels is

usually gained via transfemoral catheterization

with a 4- or 5-Fr catheter and sheath. Diagnostic

visceral arteriography, which consists of angiogra-

phy of the celiac trunk, superior mesenteric artery,

and inferior mesenteric artery, is performed to

investigate a suspicious vascular region, and a

microcatheter is then inserted coaxially for superse-

lective cannulation of the bleeding artery.

In upper GI bleeding, the source of the bleeding is

usually identified by means of endoscopy. There-

fore, angiography is most often performed only as a

precursor to transcatheter embolotherapy. Angio-

grams are considered positive when they show

either a direct angiographic sign of active GI

bleeding (i.e., extravasation of contrast medium) or

an indirect angiographic sign of bleeding (e. g.,

pseudoaneurysm). For embolization, an appropri-

ate catheter position is selected, and transcatheter

vessel occlusion is performed with an embolic

material. Embolizations are performed as selec-

tively as possible, with the catheter advanced as

close to the site of bleeding as technically feasible.

The aim is to achieve proximal and distal control of

the bleeding lesion (embolization of both the inflow

and outflow vessels) to minimize the risk of


243

recurrent bleeding via the collateral circulation.

Embolization is continued to an occlusive angio-

graphic endpoint with no antegrade arterial blood

flow in the embolized artery. Post-embolization

arteriography is performed to confirm completion

of the procedure.

The most common embolic material used to treat

upper GI bleeding is the fibered platinum microcoil,

which is usually placed in the bleeding artery in a

distal-to-proximal manner until angiographic

extravasation of contrast medium ceases and there

is complete occlusion of the bleeding vessel. Coiling

the gastroduodenal artery from the celiac axis may

be inadequate, as the gastroduodenal artery can

then be fed via collateral branches from the

superior mesenteric artery. A“sandwich”techni-

que (Figure-1) has been proposed 25) in which the

gastroduodenal artery is coiled in a distal-to-proxi-

mal manner. Sandwich occlusion can be used at the

level of the gastroduodenal artery with the catheter

pushed to the origin of the right gastroepiploic

artery, and coils are introduced into the proximal

gastroduodenal artery as the catheter is withdrawn.

Complete embolization of the gastroduodenal

artery, which includes proximal and distal emboliza-

tion and exclusion of its two side branches, is the

technical endpoint.

Selective superior mesenteric arteriography is

performed after embolization to ensure the absence

of a collateral supply to the bleeding site. If

extravasation is identified, superselective catheter-

ization of the inferior pancreaticoduodenal artery

and the side branch responsible for the collateral

circulation is performed with a microcatheter. In

the past 10 years, significant improvements in this

technique have made superselective embolization a

safer procedure by minimizing the risk of intestinal

ischemia 26) 27).

Shiraishi: Endovascular treatment of gastrointestinal bleeding

244

Figure-1 “Sandwich”embolization of duodenal diverticular bleedingA. Three-dimensional computed tomography (3D-CT) (volume-rendered image) demonstrating the anatomic structure of the abdomen.

B. 3D-CT (multiplanar-reconstruction image) showing a branch of the pancreaticoduodenal artery projecting toward the duodenal

diverticulum (arrow).

C. Selective posterior-superior pancreaticoduodenal angiogram showing no active extravasation of contrast medium.

D. Result of empiric coil embolization of the distal and proximal posterior-superior pancreaticoduodenal artery to prevent retrograde flow.

Bleeding was controlled after embolization and no ischemic complications were observed.

AABB

CC DD

The development of finer torqueable guidewires

and coaxial microcatheters, coupled with advances

in digital fluoroscopic imaging, now allows for more

precise vascular intervention. In a recent report,

transarterial embolization for upper GI bleeding

was associated with a high rate (93%) of technical

success and a minimal rate of complications (9%) 25).

Furthermore, a recently published international

consensus recommendation considers transarterial

embolization an alternative therapy for the manage-

ment of upper GI bleeding in patients in whom an

endoscopic hemostatic procedure has failed or in

those with recurrent bleeding 28).

Transarterial embolization for the treatment of

lower GI bleeding was first introduced in 1974 and

involved non-selective injection of autologous

clot 29). In 1977, injection of Gelfoam and Oxycel was

described for embolization of diverticular bleeding.

Although the injection of autologous clot or gelatin

sponge showed promise for achieving hemostasis,

these early embolization techniques were charac-

terized by high rates of bowel infarction 30) 31). The

development of coaxial microcatheters renewed

interest in using embolization to control lower GI

bleeding. Using a microcatheter delivered through

a 4- or 5-Fr guiding catheter, specific marginal

arteries or the vasa recta near the bleeding site can

be accessed for delivery of an embolic material. As

this technique is superselective, the risk of bowel

infarction is markedly lower than with non-selec-

tive embolic techniques or vasopressin infusion, and

there is none of the systemic side effects associated

with vasopressin. In addition, there is decreased

risk of bleeding from collateral vessels when the

embolic material is delivered close to the bleeding

site 30).

The most common embolic materials for lower GI

bleeding, used either alone or in combination, are

microcoils, polyvinyl alcohol (PVA) particles, and

gelatin sponge. Microcoils are permanent embolic

agents that can be placed superselectively near the

site of bleeding and are readily identifiable under

fluoroscopy. However, because of the small caliber

of the target vessels, proper deployment of these

coils can be challenging. Coils may back out of small

vessels and provoke ischemia if they enter larger

feeding vessels.

PVA is a permanent embolic agent that is less

selective than microcoils. The rationale behind

flow-directed PVA embolization is that the PVA

particles preferentially flow to the area of least

resistance (i.e., the site of bleeding) 32). Defreyne et

al. have demonstrated in 10 patients that lesions not

accessible with superselective catheterization can

be embolized safely with flow-directed PVA

embolization 32). However, consensus on the optimal

size of PVA particles for embolization in lower GI

bleeding is yet to be reached. Previous reports have

recommended PVA particles 300 to 500 μm in size,

because an earlier animal study suggested that

smaller particles may be associated with a higher

risk of bowel ischemia 30) 33).


245

AA BB

Figure-2 Superselective embolization of colonic diverticular bleedingA. Radiopaque clips were placed via colonoscopy at the bleeding point on the distal portion of the ascending colon before angiography.

Selective ileocolic artery angiogram showing intraluminal extravasation of contrast medium in the ascending colon (arrow).

B. After superselective embolization of the vasa recta with gelatin sponge particles, no extravasation or bleeding was seen on angiography.

The choice of embolic agent in relation to the

characteristics of the bleeding vessel is important,

but which embolic agent is best among coils,

cyanoacrylate glue, gelatin sponge, and calibrated

particles remains a matter of debate. In our

department, microcoils, 1,000-μm gelatin sponge

particles, and cyanoacrylate glue are used to treat

acute GI bleeding. In contrast to PVA, gelatin

sponge is a temporary embolic agent, allowing for

vessel recanalization within a few days to weeks. A

representative image of gelatin sponge emboliza-

tion of colonic diverticular bleeding is shown in

Figure-2.

If the angiogram is negative for active bleeding,

empiric embolization is performed on the basis of

discussions with the referring gastroenterologist or

surgeon (Figure-1). For empiric embolization, if

endoscopy has demonstrated that the source of

bleeding is located in the proximal stomach, the left

gastric artery is selectively embolized. If endoscopy

has demonstrated that the source of bleeding is in

the distal stomach or duodenum, the gastroduode-

nal artery, right gastroepiploic artery, pancreatico-

duodenal arcade, or all three, are selectively

embolized. If endoscopic intervention fails to control

the bleeding, radiopaque clips are positioned as a

guide at the bleeding site by means of colonoscopy

and transarterial embolization is performed to stop

the bleeding, with deposition of the coils being

guided by hemoclips placed beforehand by means

of endoscopy.

As a result, angiography and embolization of

causative vessels in GI bleeding have been gradu-

ally accepted, and this has transformed the manage-

ment of lower GI bleeding.

Complications associated with

endovascular treatment

Complications associated with embolization

include those associated with the angiography itself

(e. g., hematoma, arterial thrombosis, dissection,

embolism, pseudoaneurysm), as well as bowel

infarction. Early transcatheter interventions

involved vasopressin infusion, but a high rate of

rebleeding and a high incidence of complications led

to a reduction in its use. Higher rates of complica-

tion and rebleeding have been reported in patients

treated with vasopressin 34). Although the first

embolic techniques improved hemostasis, their

utility was limited by a high incidence of bowel

infarction 35)-37).

It was not until the advent and development of

microcatheter technology that transarterial emboli-

zation became a safe, more effective method for the

management of GI bleeding. Improvements in

microcatheter systems have allowed more selective

delivery of embolic material closer to bleeding sites;

this has bypassed the systemic side effects of

vasopressin and led to lower risks of bowel

infarction and bleeding from the collateral vessels.

Recently, many reports have suggested that

superselective embolization for the management of

GI bleeding rapidly stops bleeding with minimal

risk of ischemia 20) 21) 27) 38)-49). However, the risk of

ischemia after embolization is increased in patients

with a history of surgery within the same area 50) or

when the therapeutic intervention involves embolic

agents that can advance far into the vascular bed.

Such agents include liquids (e.g., tissue adhesives

such as cyanoacrylate) or very small particles (e.g.,

gelatin sponge powder or calibrated micro-

spheres) 50)-53).

Multi-detector row computed tomography

In stable patients, multi-detector row computed

tomography (MDCT) imaging is a useful tool for

locating bleeding sites and evaluating the anatomic

structure of the GI tract, thereby enabling more

focused intervention. Technetium-99m red blood

cell scintigraphy has a sensitivity and specificity of

more than 90%; however, its limited resolution does

not allow precise diagnosis.

Computed tomography angiography (CTA) has

also been used (sensitivity up to 86%) in the

diagnosis of acute GI bleeding and can be used to

precisely determine the location and etiology of the

bleeding, and thereby direct further manage-

ment 54). A positive MDCT angiogram can be useful

to select appropriate patients for rapid targeted

embolization. Visualization of active extravasation

of contrast medium in the GI tract requires careful

attention to technique, including the use of thin

collimation, rapid contrast-medium administration,

and appropriate scan timing. The additional use of

multiplanar reconstructions and three-dimensional

imaging is beneficial in identifying the exact source


246

of the bleeding.

Although further studies are needed to address

which course of action is best when bowel prepa-

ration cannot be performed, CTA may be useful in

this situation for identifying the bleeding site 55).

Conclusion

Improvements in catheter technology, the devel-

opment of more compatible embolization agents,

and the expansion of embolization techniques have

resulted in the increased use of angiography and

embolization for the treatment of both upper and

lower GI bleeding. Transcatheter embolization

therapy for the treatment of acute GI bleeding is a

safe procedure with high rates of technical and

clinical success, but it should be reserved as a

treatment option for patients who have failed

endoscopic and medical management. MDCT

imaging is a useful tool for identifying the bleeding

site and evaluating the anatomic structure of the GI

tract in stable patients. Close working relationships

among interventional radiologists, gastroenterolo-

gists, and diagnostic radiologists are necessary for

optimal management of patients with GI bleeding.

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248

Special Reviews:Farewell Lectures ofRetiring Professors


Future Chemotherapy Preventing Emergence of Multi-Antibiotic Resistance

KEIICHI HIRAMATSU＊1), TAKASHI SASAKI＊2), YUH MORIMOTO＊1)

＊1)Juntendo Research Centre for Infection Control Science, Juntendo University Graduate School of Medicine, Tokyo, Japan

＊2)Department of Microbiology, Juntendo University Faculty of Medicine, Tokyo, Japan

The authors and all of the faculty at the Department of Bacteriology (Dept. of Microbiology from April 2015)

have studied methicillin-resistant Staphylococcus aureus (MRSA), a representative multi-drug-resistant

pathogen prevalent globally. During this study, we have identified the extreme flexibility of this organism to

survive antibiotic pressure. S. aureus is part of the normal flora of human beings, yet it possesses high pathogenic

potential, being aptly called ʻthe department of toxinsʼ. We are probably destined to continue our lives in

association with this dangerous neighbor. For this reason, in 2008, KH launched a new project searching for novel

antibiotics that are effective against MRSA. A newly found antibiotic called nybomycin has a curious property: it

is effective against quinolone-resistant S. aureus strains (including most MRSA), but not against quinolone-sus-

ceptible ones. Moreover, the mutant strains derived from the parent S. aureus strain after treatment with

nybomycin were cured of their quinolone resistance. Subsequently, we found an antibiotic with the same property

in flavones, too. We designated these antibiotics with such unique properties reverse antibiotics (RA). By using

RA and extant antibiotics in a well-controlled way, we should be able to establish sophisticated anti-microbial

chemotherapy in the future.

Key words: reverse antibiotic (RA), MRSA, VISA, quinolone, vancomycin

Introduction

After graduation from Tokyo University Medical

School in 1975, the author (KH) studied internal

medicine (1975-1978). Then he conducted research

on cellular immunology (1978-1980), and then

retrovirology (Human T-cell Lecukemia Virus I

[HTLV-I]) (1984-1988) before he commenced

research on methicillin-resistant Staphylococcus

(S.) aureus (MRSA) at Juntendo University. It was

a precious experience to have belonged to various

fields of medical science and had a chance to extract

and learn the essence of science in general. It was

also very precious to have learned the cutting-edge

of genetic engineering in the S. Tonegawaʼs lab at

MIT (1981-1983).

Since 1989, KH joined Department of Bacteriol-

ogy lead by late Professor Takeshi Yokota, and

started the study of MRSA. Here briefly described

are what he learned through the research and the

reason why he commenced a new project of drug

discovery and development lately against MRSA

and related multi-drug resistant pathogens.

MRSA is a multi-drug resistant pathogen

When the author (KH) started the research on

MRSA at Juntendo, little was known about the

genetic basis for methicillin resistance except for

successful cloning of mecA gene that encodes the

resistance by the M. Matsuhashiʼs group at Tokyo

University 1). The author then cloned the same gene

from another MRSA strain N315, and found that the

mecA composes an operon together with mecR1

and mecI regulator, the regulator genes that is

involved in the induction of mecA gene upon

249

Corresponding author: Keiichi Hiramatsu

Juntendo Research Centre for Infection Control Science, Juntendo University Graduate School of Medicine



335th Triannual Meeting of the Juntendo Medical Society: Farewell Lectures of Retiring Professors〔Held on Mar. 24, 2015〕

〔Received Apr. 27, 2015〕

exposure to β-lactam antibiotics. Meantime, mecA

was shown to encode a β-lactam non-sensitive cell-

wall synthesis enzyme PBP2ʼ (penicillin-binding

protein 2ʼ). It is a transpeptidase used to produce

cross-linkage between the peptidoglycan (PG) nas-

cent chains to make a rigid and durable cell-wall of

S. aureus. As the name suggests the activity of PBP

is the target of penicillin and is inhibited by it and

other β-lactam antibiotics. Since its first discovery

in 1961 2), MRSA has turned down all the new

antibiotics, the fruits of the anti-bacterial chemo-

therapy era started in 1940s. By 1970s, MRSA have

acquired the resistance to practically all the

available antibiotics, and has become the symbol of

multi-drug resistant pathogen.

Hiramatsu, et al: Reverse antibiotics as novel chemotherapeutics

250

Figure-1 SCCmec: Methicillin resistance gene mecA is carried by a mobile element Staphylococcal Cassette Chromosome(SCC)

The first step of our study was to reveal that methicillin resistance genemecA and its regulator genes were carried by a novel mobile element

staphylococcal cassette chromosome (SCC). SCC is a stretch of DNA demarkated by a couple of inverted repeats. Its movement is driven by

ccr, cassette chromosome recombinases encoded by ccr gene complex. We named the SCC containing mec gene complex as SCCmec.

IR IR

ccr gene complex

mec gene complex

mec gene complex is composed of mecA and its regulator genes mecR1 and mecIccr gene complex encodes cassette chromosome recombinases

IS431ΨmvaS

mecAmecR1

mecI

Tn554

ccrAB（C）

Figure-2 SCCmec is site-specifically integrated in Staphylococcus aureus chromosomeThe whole genome illustration of three MRSA strains. N315 and Mu50 are Japanese representative Healthcare-associated MRSA strains.

MW2 is an USA400 that is a highly virulent representative Community-acquired MRSA.

SCCmec in yellow is shown to be site-specifically integrated near the origin of replication. Note that the SCCmec in community-acquired

MRSA is much shorter than those in healthcare-associated strains. The chromosomal location of genomic islands encoding pathogenicity

factors are illustrated in red or pink: ν signifies ʻislandʼ in Latin, ϕ, stands for integrated bacteriophage. For detail, see references (13, 14, 16).

oriC

0.0

0.5

1.02.0

1.5

2.5

orfX SCCmec

νSaα

νSa3

φSa1mw

φSa2mw

νSaβ

φSa3νSa4

N315

Mu50

MW2

MW2

mecA gene is transferred across staphylococcal

species

By chromosome walking of N315 and the other

two representative world-wide epidemic MRSA

strains, KH and T. Ito discovered the mobile genetic

elements, staphylococcal cassette chromosome mec

(SCCmec), on which mecA gene is carried (Fig-

ure-1). SCCmec is integrated site-specifically near

the origin of replication (oriC) of the S. aureus

chromosome (Figure-2). SCCmec is an interspecies

carrier of mecA gene that confers methicillin resis-

tance on practically any staphylococcal species 3).

By developing the typing method of SCCmec his

team proved that new MRSA clones were rapidly

emerging from the S. aureus community strains.

Type I〜III SCCmec are predominant in the

healthcare-associated (HA)-MRSA4) 5), whereas

types IV and V SCCmec were found in newly

emerging community-associated (CA)-MRSA (2002

〜2004)6)-8). By 1995, elucidation of SCCmec and the

sequence around its integration site culminated into

the development of the method to discriminate

MRSA from methicillin-resistant strains of other

staphylococcal species (mec right extremity poly-

morphism [MREP] typing) 9). With this strategy

the PCR-based rapid and specific detection of

MRSA became possible, and used all over the world.

Until recently, the origin of mecA was not

identified, which was finally elucidated in 2010 10).

Practically identical mecA-mecR1-mecI gene com-

plex and surrounding area in SCCmec was found on

the chromosome of S. fleurettii, an animal commen-

sal staphylococcus. S. fleurettii is one of the oldest

staphylococcal species emerged about 200 million

years ago around the historic emergence of mam-

mals. The observation lead us to the hypothesis that

mecA gene had existed long before the birth of

humans, and then was lost from the genome of the

descendant staphylococcal species that successfully

established symbiotic relationship with their mam-

malian hosts (Figure-3).

Discovery of vancomycin resistance in MRSA

In 1997, KH and S. Hori discovered clinical strain


251

Macrococcus caseolyticus

S. aureus group

S. haemolyticus group

S. simulans groupS. pettenkoferiS. xylosus group

S. sciuri group

Primates

Glires

Eulipotyphla

Euarchontoglires

XenarthraAfrotheriaMarsupialiaMonotremata

Laurasiatheria（except for Eulipotyphla）

300 250

S. fleurettii mecA

SCCmecSCCmec

200

S. fleurettii is one of the oldest staphylococcal species diverged about 250 million years ago

150 100 50 0 （million years）Dinosaur

Placentalia

Marsupials

Mammals

Extinct

S. rosti group

S. delphini groupS. auricularis

Figure-3 Origin of mecA gene -our hypothesis-In the geological years of Dinosaur, S. fleurettii possessed mecA on the chromsome.

Degraded remnants of mecA genes are found in the chromosomes of sciuri group of species.

At around the same geological years mammals emerged. Then staphylococci colonized mammals and started co-evolution. Then

Staphylcocci were protected by the host animals from soil bacteria producing β-lactam antibiotics. Disuse lead mecA to decay, but intact

mecA was cut out from the chromosome of S. fleurettii, and preserved in the form of SCCmec among the staphylococcal species.

Mu50, the first vancomycin-intermediate S. aureus

(VISA) strain in the world, and hetero-VISA

(hVISA) strain Mu3 11) 12) as well. In 2001, during

the course of genetic investigation on vancomycin

resistance of VISA strain Mu50, the first S. aureus

whole genome sequencing (using strains Mu50 and

N315) was achieved in collaboration with several

laboratories in Japan and National Institute of

Technology and Evaluation (NITE) 13). Then, whole

genome sequences of highly virulent CA-MRSA

strain MW2 in 2002 14), and other related species and

strains were determined during 2005〜2008 at

Juntendo 15)-17).

Based on the continuous research on VISA

strains, KH and colleagues proposed thickening of

the cell-wall peptidoglycan (PG) layer, and ʻPG

cloggingʼ as the vancomycin resistance mechanism

in VISA18) 19). PG clogging is a unique mechanism of

resistance relevant so far only to vancomycin. The

obliteration of PG mesh occurs during the transit of

vancomycin molecules from outside the cell to the

cytoplasmic membrane where the target of vanco-

mycin, D-Alanyl-D-Alanine residues, are present.

Besides these real targets of action, PG layers

contain thousands of D-Alanyl-D-Alanine determi-

nants, to which vancomycin binds without causing

any disadvantage to the cell. When the cell-wall

peptidoglycan thickens, these ʻfalse targetsʼ of

vancomycin critically serve as the barrier for

vancomycin penetration and cause the delay the

reach of vancomycin to the real targets on

cytoplasmic membrane 20).

Uncovering genetic changes that casue vancomy-

cin resistance in S. aureus has been the major

theme of study of our laboratory, and was inten-

sively studied by L. Cui, Y. Katayama, and M.

Matsuo. Now, it became clear that vancomycin

resistance in VISA are the cumulative outcome of

the effects of multiple mutations. Such regulator

genes as vraSR, graRS, and walK, rpoBC genes

encoding RNA polymerase β and β ʼ subunits, and

the genes involved in PG synthesis (pbp4) and

cell-wall teichoic acid biosynthesis (tarA, tarO,

tarL) contributed to the VISA phenotype expres-

sion 21-23). Also mutation of the genes involved in

various metabolic pathways such as of pyrimidine,

amino acids, and pyruvate were also found to

contribute to the rise of vancomycin resistance 23).

Single or combinations of these mutations easily

raise vancomycin resistance. Therefore, it is not

surprising even if some of the vancomycin-suscep-

tible clinical strains generate VISA strains at a high

frequency of around one in 106 colony forming units

(CFU) when exposed to vancomycin. Such strains

are designated heterogeneously vancomycin resist-

ant or hetero-VISA (hVISA).

Figure-4 shows analysis of vancomycin suscepti-

bility of three categories of clinical S. aureus strains.


252

Figure-4 Three categories in vancomycin-susceptibility within S. aureus clinical strainsHetero-VISA strain Mu3 is not recognized as resistant to vancomycin because most of the cells (99.99%) are unable to grow on the agar

plates containing more than 4 mg/l of vancomycin. However, it contains cell subpopulations that have various degrees of vancomycin

resistance. FDA209P is one of the old isolate of S. aureus which has not been exposed to any of the hundreds of antibiotics humans have ever

introduced into clinical use since 1940s. The other three are MRSA strains isolated in recent years.

Mu50

Mu3

H1

0 13121110987654321

1

8

7

6

5

4

3

2

Vancomycin concentration（mg/l）

FDA209P

Grown colonies（log 10）

Up to 107 cells of the strains were spread on the agar

plates containing varied concentrations of vancomy-

cin. Most of the cell population of Mu3 is susceptible

to vancomycin, but it contains highly resistant cells

that can grow even in 8 or 9 mg/l of vancomycin

(Figure-4). Quite a few fractions of clinical MRSA

strains are suspected to be hVISA, but accurate

prevalence is difficult to evaluate because of the

lack of easy test method.

We also noticed that vancomycin has insufficient

cytokilling activity against MRSA. Some MRSA

strains are found to be ʻtolerantʼ (i.e., they survive

the exposure to much higher concentrations of

vancomycin than needed to inhibit their growth).

ʻSlow VISAʼ (sVISA) is a novel phenotype of

vancomycin resistance derived from hVISA strains

that is characteristic in its extremely prolonged

growth rate and resistance as well as tolerance to

higher concentrations of vancomycin as compared

to VISA24). The remarkable feature of the sVISA

phenotype is its instability. The sVISA phenotype

of the strains disappears within 7 daysʼ drug-free

passages, and they return to hVISA strains 24). It is

probable that this phenomenon occur in clinical

settings, which causes the therapeutic failure of the

infection caused by the MRSA strains having

susceptible ranges of vancomycin MICs (i. e. ≤ 2

mg/l). Vancomycin has long been freed from

drug-resistance development from its first discov-

ery in 1956 until recently 11). However, it is now clear

that vancomycin has gradually had lost reliability in

the treatment of MRSA infection, and we have no

alternative antibiotic effective against it.

Discovery of reverse antibiotics (RA)

Since 2008, KH, and Y. Morimoto, started a

project of searching for natural antibiotics effective

against multi-drug resistant MRSA. Screening of

about 2,000 Actinobacteria cultures hit one queer

substance. The substance was identified as an

nybomycin, which was first reported in 1955 25).

Surprisingly, nybomycin was found to be active

against quinolone-resistant S. aureus but was

inactive against quinolone-susceptible S. aureus26)

(Table-1). This curious property of nybomycin was

not noticed before, because the year of its discovery

was long before the human development of nalidixic

acid, the first quinolone antibiotic in 1962. Like

quinolone antibiotics, nybomycin also allowed the

emergence of resistant mutant strains. However, it

turned out that the nybomycin-resistant mutants

have lost quinolone resistance and become suscepti-

ble to quinolone antibiotics (Figure-5). Quinolone

resistance is generated when a type-II topoisomer-

ase gene (gyrA or parC) is mutated. Topoisomerase

inhibition assay revealed that nybomycin binds to

the mutated topoisomerases with much greater

affinity than to non-mutated wild-type topoisomer-

ases. This discovery prompted KH to look for other

substances that bind to bacterial type-II topoiso-

merases. Literature search hit an old reference that


253

Figure-5 Nybomycin is a Reverse Antibiotic for Quinolone ResistanceIt turned out that nybomycin also produces resistant mutants. But, curiously, they carry back mutated wild-type GyrA, to which quinolones

are effective.

Ciprofloxacin GyrA Mutation

Quinolone SensitiveNybomycin Resistant

GyrA Reverse MutationNybomycin

Quinolone ResistantNybomycin Sensitive


254

Straina

Cou

ntry

Yea

rof

Isolation

AA

substitionb

MIC

(mg/l)c

parC

GyrA

VAN

OXA

NOR

CIP

OFX

LVX

TSX

SPX

NYB

API

NCTC83

25UK

1943

MSSA

ww

11

10.

250.

250.

125

≤0.

060.

125

>64

>12

8

FDA

209P

UK

1948

MSSA

ww

0.5

≤0.

060.

250.

125

0.12

5≤

0.06

≤0.

05≤

0.06

6412

8

N31

5Japan

1982

MRSA

ww

0.5

321

0.25

0.25

0.12

5≤

0.06

≤0.

0664

>12

8

Mu50

Japan

1996

MRSA

Ser80

Phe

Ser84

Leu

8>12

812

832

168

>12

816

0.25

4

VRS1

USA

2002

VRSA

＊Ser80

Phe

Ser84

Leu

>12

8>12

8>12

812

832

164

80.

125

4

HIP

0792

0USA

1998

MRSA

Glu84

Lys

Ser84

Leu

212

816

1616

84

160.

254

HIP

5836

(NJ)

USA

1997

MRSA

Ser80

Tyr

Ser84

Leu

864

128

1664

832

320.

52

HIP

0793

0USA

1999

MRSA

Ile4

5Met,Ser80

Phe

Ser84

Leu

412

816

1616

816

160.

254

NRS11

8USA

2002

MRSA

Ser80

Phe,

Ser81

Pro

Ser84

Leu

8>12

812

832

6432

>12

832

0.25

4

VRS3a

USA

2004

VRSA

＊Ser80

Tyr,Glu84

Lys

Ser84

Leu

>12

812

812

864

3216

>12

816

0.12

52

HIP

0966

2USA

2000

MRSA

Ser80

Phe,

Glu84

Gly

Ser84

Leu

4>12

864

3232

32>12

816

14

VRS5

USA

2005

VRSA

＊Ser80

Tyr,Glu84

Gly

Ser84

Leu

>12

8>12

8>12

8>12

864

32>12

816

≤0.

062

HIP

0914

3USA

2000

MRSA

Ser80

Phe,

Glu84

Lys

Ser84

Leu

4>12

8>12

864

6432

>12

816

0.25

2

KSA36

Japan

2005

MRSA

Ser80

Tyr

Ser84

Leu

,Glu88

Gly

1>12

8>12

812

8>12

8>12

8>12

812

8≤

0.06

0.5

VRS4

USA

2005

VRSA

＊Ser80

Tyr,Glu84

Gly

Ser84

Leu

,Glu88

Lys

>12

832

>12

8>12

8>12

8>12

8>12

8>12

8≤

0.06

2

KBSA72

Japan

2005

MRSA

Ser80

Tyr,Glu84

Lys

Ser84

Leu

,Glu88

Gly

112

8>12

812

8>12

8>12

8>12

812

8≤

0.06

0.5

KBSA56

Japan

2005

MRSA

Ser80

Tyr,Glu84

Val

Ser84

Leu

,Glu88

Gly

132

128

64>12

8>12

8>12

8>12

8≤

0.06

0.5

MIC

,minim

um

inhibitoryconcentration;VAN,van

comycin;OXA,oxacillin;NOR,norflox

acin;CIP

,ciproflox

acin;OFX,oflox

acin;LVX,lev

ofloxacin;TSX,tosuflox

acin;SPX,sparflox

acin;NYB,

nybom

ycin;API,ap

igen

in.

aStrainsarelisted

from

topto

bottom

inorder

ofthenumber

ofam

inoacid

substitution

(s)in

thequinolon

eresistan

ce-d

eterminingregion(Q

RDR).

bAminoacid

substitution

siden

tified

intheQRDR

ofParC

andGyrA

:w

indicates

wildtype.

cQuinolon

ean

dnybom

ycinMIC

s≥8mg/l

arein

bold.

＊VRSA,van

comycin-resistantStaphylococcusaureus;defined

byVCM

MIC

of≥

16mg/l

(20)

.

Tab

le-1

Alternatesu

scep

tibilitypattern

ofQuinolon

ean

tibiotics

andRA

(Nybom

ycinan

dApigen

in)ag

ainstS.aureusclinical

strainsof

theworld

withvariousgen

otypes

oftype-II

topoisomerasegen

es

reported the marginal levels of activity of flavones

in the inhibition of E. coli DNA gyrase 27). By testing

104 flavones, we found apigenin and several other

flavones shared a property of reverse antibiotic.

They inhibited mutated DNA gyrase of S. aureus,

while they had practically no activity against

wild-type DNA gyrase (Table-1).

Nybomycin and apigenin are considered to

represent a novel functional class of antibiotics.

They are active against quinolone-resistant bacte-

ria but inactive against quinolone-susceptible ones.

Thus, they can be used to cope with quinolone-

resistant bacteria which are predominant in nosoco-

mial environments. Although at a low frequency of

around one in 1011, resistant mutants against

nybomycin do emerge. We found that these

resistant mutants harbored the wild-type gyrase

gene. Since the quinolone-resistant strain has a

mutation in the gyrase gene, the back (or reverse)

mutation of which cured the bacteria of quinolone

resistance and achieved instead the resistance to

nybomycin or flavones. We named these new class

of antbiotics as ʻreverse antibiotics (RA)ʼ for

quinolone resistance.

Future chemotherapy

Now it is clear that no antibiotic is free from

emergence of resistance. That is an invaluable

lesson of nature we drew through the experience of

anti-microbial chemotherapy since 1940s. Resist-

ance is inevitable and had long existed much before

the use of antibiotics by mankind in commercial

scale. However, existence of resistant bacterial

population is not hazardous to us if we have in our

arsenal an antibiotic specifically effective on it.

Thanks to the rapid progress in genome sequence

technology, many new targets for antibiotic devel-

opment have been found. However, introduction of

any new antibiotic would end up with another cycle

of resistance formation. Nybomycin and flavones, on

the other hand, share the well known ʻoldʼ targets of

action with quinolone antibiotics. Closer look at the

ligand-binding mode by the target molecule

revealed an alternate binding of nybomycin and

quinolones to the wild-type and mutated DNA

gyrases. This provides the basis for the reciprocal

nature of antibiotics and RA. RA would not be

confined to quinolone targets. Future well-tem-

pered use of RA and antibiotics against various vital

targets of action would allow the advent of new era

of anti-microbial chemotherapy based on the

principles of nature.

Acknowledgement

The authors are thankful to all the members of

Dept of Bacteriology and COE Infection Control

Science. Special thanks goes to Kyoko Kuwahara-

Arai, Tadashi Baba, Yuki Katayama, Miki Matsuo

and Tomomi Hishinuma for their invaluable contri-

bution to the field of study. This work was

supported by a Grant-in-Aid for Young Scientists

B (24791029) and a grant-in-aid (S1201013) from

the Ministry of Education, Culture, Sports, Science,

and Technology Japan (MEXT) for the Foundation

of Strategic Research Projects in Private Univer-

sities.

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256



New Biomarkers for Diagnosis in Patients with Chronic Kidney Disease (CKD)

YASUHIKO TOMINO＊

＊Division of Nephrology, Department of Internal Medicine, Juntendo University Faculty of Medicine, Tokyo, Japan

In Japan, major causes of end-stage kidney disease (ESKD) are type 2 diabetic nephropathy, IgA nephropathy,

and nephrosclerosis. Renal replacement therapies are hemodialysis (HD) and peritoneal dialysis (PD). Since PD

patients have shown some complications, such as peritonitis, infections of the exit sites of catheters, and

encapsulated peritoneal sclerosis (EPS), it is necessary to determine infections at an early stage of PD. Although a

definite diagnosis in patients with chronic kidney disease (CKD) is made through the biopsy of renal tissue and

peritoneum, we cannot always perform such diagnostic procedures. Thus, it is necessary to develop non-invasive

diagnostic biomarkers prior to biopsies in CKD patients. The objective of this review is to explain the efficacy of

new biomarkers in such patients.

Key words: diabetic nephropathy, IgA nephropathy, peritoneal dialysis, chronic kidney disease (CKD)

Introduction

Chronic kidney disease (CKD) is a worldwide

public health problem that affects millions of people

from all racial and ethnic groups. According to the

2013 annual report by the Japanese Society of

Dialysis Therapy (JSDT) 1), the total number of

dialysis patients was 314,180, and the leading cause

of end stage kidney disease (ESKD) has been

diabetes (43.8%), instead of chronic glomerulo-

nephritis (18.8%), since 1998. In Japan, major

causes of ESKD are type 2 diabetic nephropathy,

chronic glomerulonephritis, especially IgA nephrop-

athy, hypertensive nephrosclerosis, and polycystic

kidney disease. The pathogenesis of diabetic

nephropathy includes genetic factors and/or envi-

ronmental factors such as life style impairment and

metabolic syndrome. Since the pathogenesis of IgA

nephropathy is still obscure, the efforts made by

many investigators around the world have gradu-

ally clarified various aspects of the pathogenesis

and treatment of IgA nehropathy. In Japan, the

major renal replacement therapies are hemodialysis

(HD) and peritoneal dialysis (PD), but not renal

transplantation. Since PD patients have shown

some complications, such as peritonitis, infections of

the exit sites of catheters, and encapsulated

peritoneal sclerosis (EPS), it is necessary to deter-

mine infections at an early stage of PD. It is

necessary to develop non-invasive diagnostic bio-

markers prior to biopsies in patients with CKD.

The objective of this review is to explain the

efficacy of new biomarkers in CKD patients, such as

type 2 diabetic nephropathy, IgA nephropathy, and

peritoneal fibrosis based on clinicopathological

findings.

Type 2 diabetic nephropathy

Although renal biopsy is not performed on all

patients with diabetes for a definite diagnosis,

clinical diagnostic criteria are usually used in Japan

(Figure-1, Table-1). The presence of diabetic reti-

nopathy and/or neuropathy are important findings

for clinical diagnosis.

257

Yasuhiko Tomino

Division of Nephrology, Department of Internal Medicine, Juntendo University Faculty of Medicine

2-1-1 Hongo, Bunkyo-Ku, Tokyo 813-8421, Japan



〔Received Dec. 16, 2014〕

1. New biomarkers using urine and serum sam-

ples

Macisaac et al. 2) reported markers and risk

factors for the development and progression of

diabetic kidney disease. Emerging risk factors for

the progressive loss of renal function include

markers of oxidation and inflammation, profibrotic

cytokines, uric acid, advanced glycation end prod-

ucts (AGEs), functional and structural markers for

vascular dysfunction, renal structural changes, and

tubular biomarkers. They reported that the most

promising are serum uric acid and soluble tumor

necrosis factor (type 1 and type 2) levels, especially

in relation to GFR changes 2).

1) Urine sample

・Albumin

Microalbuminuria is a major clinical sign in the

early stage of diabetic nephropathy. Although signifi-

cant renal histological changes have already appeared

even at the stage of microalbuminuria or impaired

glucose tolerance (IGT), it is necessary to develop

more sensitivemarkers for detecting early stage renal

injury in patients with type 2 diabetic nephropathy. In

Japan, patients with diabetic nephropathy are classi-

fied into the following five stages. Stage I (normoalbu-

minuria stage) shows a normal or increased estimated

glomerular filtration rate (eGFR) (more than 30 ml/

min of eGFR). Stage II (microalbuminuric stage)

shows microalbuminuria (30-299 mg/g Cr of urinary

albumin excretion, more than 30 ml/min of eGFR).

Stage III (macroalbuminuric stage) shows macroal-

buminuria (more than 300 mg/g Cr of urinary albu-

min excretion, more than 30 ml/min of eGFR). Stage

IV (renal failure stage) shows a decrease of renal

function (less than 30 ml/min of eGFR). Stage V is a

dialysis stage.

Horikoshi et al. 3) have developed a highly sen-

sitive and inexpensive method for testing urinary

protein levels that is based on a dye-binding

method using erythrosin B. A solution containing a

buffer agent (pH 2.3) and surfactants, and a solu-

tion of erythrosin B are added to a urine sample.

After letting the mixture stand at 37℃ for 5 min,

the dye-bound protein is measured by a spectro-

photometer at 546 nm using a Hitachi 779S auto-

mated analyzer (Tokyo, Japan). The calibration

curve was linear with a human serum albumin

concentration in the range of 2.4-200 mg/l. The

detection limit, 2.4 mg/l, was superior to conven-

tional dye-binding methods by one order of mag-

nitude and comparable to a turbidimeric immunoas-

say (TIA). The erythrosin B method showed an

excellent correlation and equal sensitivity with

TIA. Spot urine samples from 70 patients who

showed (−) or (±) in a dip-stick screening test

for proteinuria and 79 healthy controls were

analyzed. There was an excellent correlation (r =

0.978, n = 149) between the results given by the

proposed method and those by the TIA. This

sensitive method to measure urinary protein will

be useful for the screening of microalbuminuria

because proteinuria in early stages of kidney

diseases mostly consist of albumin. A high-perform-

ance liquid chromatography (HPLC) assay, which

we reported as a sensitive method to detect micro-

albuminuria 4), is also available but costs the same

amount as TIA. The erythrosin B method has a 70%

cost savings compared with TIA 3).

・MCP-1, IL-8, MMP-9 and Mindin

Tashiro et al. 5) examined the correlation among the

levels of urinary monocyte chemoattractant protein-1

(MCP-1) and interleukin-8 (IL-8), hyperglycemia,

Tomino: New biomarkers in CKD patients

258

Figure-1 Exudative lesion of type 2 diabetic nephropathyCapsular droplets in the Bowmanʼs capsules and exudative lesions

are also observed in a patient with diabetic nephropathy (PAS

staining).

1) History of diabetes: more than five years

2) Presence of diabetic retinopathy and/or neuropathy

3) Persistent proteinuria or albuminuria

4) No severe hematuria and/or cellular casts

5) Increase of GFR and enlargement of kidneys: occasionally(especially in the early stage)

(Report of the Ministry of Health and Welfare, Japan, 1991)

Table-1 Diagnostic criteria of type 2 diabetic nephropathyin Japan

and renal injuries in patients with type 2 diabetic

nephropathy. High glucose may stimulate MCP-1

and/or IL-8 production and their excretion into the

urine, independent of the phases or pathological

lesions of this disease. It is indicated that IL-8

increases in an early stage of diabetic nephropathy,

and MCP-1 increases in an advanced stage of

diabetic nephropathy. It appears that the measure-

ment of urinary MCP-1 and IL-8 may be useful for

evaluating the degree of renal injuries in patients

with type 2 diabetic nephropathy 5). We also

determined correlations among the levels of urinary

matrix metalloproteinase-9 (MMP-9) and type IV

collagen, hyperglycemia, urinary protein, and renal

injuries in patients with type 2 diabetic nephro-

pathy 6). Patients with type 2 diabetic nephropathy

were divided into two groups: Group 1, patients

with normoalbuminuria or microalbuminuria (0-

299 mg/g Cr), and Group 2, patients with macroal-

buminuria (> 300 mg/g Cr). The mean level of

urinary MMP-9 in patients with type 2 diabetic

nephropathy increased in accordance with the

clinical stage of the disease. The mean level of

urinary type IV collagen in Group 2 patients with

diabetic nephropathy was significantly higher than

that in Group 1 and healthy controls. The levels of

urinary type IV collagen in patients with diabetic

nephropathy were also increased in accordance

with the clinical stage of the disease. It appears that

the measurements of urinary MMP-9 and type IV

collagen may be useful for evaluating the degree of

renal injuries in patients with type 2 diabetic

nephropathy, especially in an early stage 6).

Increasing evidence indicates that the inflamma-

tory and immune response mechanisms may con-

tribute significantly to the development of diabetic

nephropathy. Inflammatory biomarkers should be

useful in the diagnosis or monitoring of diabetic

nephropathy. Mindin (spondin 2) is a member of

the mindin-/F-spondin family of secreted extracel-

lular matrix (ECM) proteins. Previous studies

showed that mindin is essential for the initiation of

innate immune reponses and represents a unique

pattern-recognition molecule in ECM proteins.

Urinary mindin excretion in patients with type 2

diabetes was increased compared with that in

healthy controls, reflecting the stage of diabetic

nephropathy. It appears that urinary mindin is a

potential biomarker in the development of diabetic

nephropathy patients 7).

2) Blood sample

・TNF receptors

Chronic inflammation promotes the progression

of diabetic nephropathy. A number of studies have

documented significantly higher circulating concen-

trations of tumor necrosis factor (TNF) pathway

related molecules such as TNFα and TNF receptors

(TNFRs) in CKD patients, and those levels are

closely correlated with the change of GFR 8). TNFα,

a pleiotrophic cytokine, may play important inflam-

matory roles in various renal diseases such as lupus

nephritis, anti-neutrophil cytoplasmic antibody

(ANCA) -associated glomerulonephritis, and renal

allograft rejection. However, the role of TNFα

remains unclear in patients with type 2 diabetic

nephropathy. TNFα is a functional 26kDa homo-

trimer type II transmembrane protein. It is a

central proinflammatory cytokine that is generated

in a wide variety of cells, including monocytes,

macrophages and T cells, fat cells, and endothelial

cells. Gohda et al. 9) reported that the concentrations

of TNFRs strongly predict early and late renal

function loss in both type 1 and 2 diabetes, inde-

pendent of classical risk factors such as GFR and

albuminuria. Type 1 diabetic patients with normo-

or microalubuminuria and with TNFR2 levels in the

highest quartile had a 55% cumulative incidence

rate of reaching CKD stage 3, compared with a less

than 15% incidence rate for patients with TNFR2

levels in the lower 3 quartiles after 12 years of

follow-up. Type 2 diabetic patients with proteinuria

and with TNFR1 levels in the highest quartile had a

nearly 80% cumulative incidence of progression to

ESKD after 12 years of follow-up, the rate was less

than 20% in those with TNFR1 levels in the lowest 3

quartiles 9) 10). Furthermore, the concentration of

TNFRs also predicted caridovascular and all-cause

mortality, but these effects were smaller than those

observed in ESKD.

IgA nephropathy

1. New biomarkers using serum samples

・Galactose-deficient IgA1 (Gd-IgA1) immune com-

plex

IgA nephropathy is the most common type of

primary chronic glomerulonephritis worldwide.

IgA nephropathy has a significant morbidity, culmi-


259

nating in ESKD in about 40% of patients within 20

years of the diagnosis (Figure-2, 3). Renal biopsy is

required for the diagnosis of IgA nephropathy. We

have already reported the importance of four

clinical markers in the diagnosis of patients with

IgA nephropathy, or in the differential diagnosis

from other types of primary chronic glomerulo-

nephritis, as follows: 1) more than five red blood

cells (RBCs) in urinary sediments, 2) persistent

proteinuria (urinary protein of more than 0.3 g/

day), 3) a serum IgA level of more than 315 mg/dl,

and 4) a serum IgA/C3 ratio of more than 3.01.

Patients with three or four clinical markers were

easily diagnosed as having IgA nephropathy in our

previous reports 11). However, it is necessary to

develop new biomarkers for the early detection of


260

Figure-2 Histopathological characteristics in a patient with IgA nephropathyA. Immnunofluorescence. Left: IgA deposition, Right: C3 deposition

B. Light microscopic finding. Arrow: Paramesangial deposits

C. Electron microscopic finding: Electron dense deposits in the paramesangial area

Figure-3 Pathogenesis of IgA nephropathy patients

　Berger J, et al: Nephropathy with mesangial IgA and IgG deposits.　IgA nephropathy is chronic mesangial proliferative glomerulonephritis associated withIgA and IgG deposits observed by immunofluorescence（1968）．

Pathogenesis is still obscure

BA C

Progression of IgA nephropathyUnderglycosylated IgA1 deposition in mesangial areas/cells

（activation）

Cytokine, chemokine and growth factorsReactive oxygen species（ROS）Complement （local production）

Platelet aggregation/Blood coagulationAdhesion molecules

Cell infiltration

Genetic factors

ChemokineCytokineTransferrinComplementFcRn（IgG）

Tubular damage

Podocyte damage

Mesangial expansion

Glomerulus Cell proliferation

？

？

Repair

ApoptosisProteinuria

Tubulo－interstitialCross－talk

resultcause

Interstitial damagemacrophage, lymphocyte,mast cell, fibroblast

ESKD

this disease without renal biopsy.

Several recent studies suggest that aberrant

O-glycosylation of circulatory IgA1 is vital in the

pathogenesis of IgA nephropathy. The O-linked

glycans in the hinge region of IgA1 are generally

composed of N-acetylgalactosamine (GalNAc) and

galactose; sialic acid may be attached to either or

both sugars. IgA1-producing cells secrete a mix-

ture of IgA1 O-glycoforms. Studies in the different

populations have shown that IgA nephropathy

patients have significantly higher levels of circulat-

ing IgA1 with galactose-deficient, O-linked, hinge-

region glycans 12). Depending on the population

studied, 50-75% of IgA nephropathy patients have

levels above the 90th percentile for healthy controls.

In addition, IgA1 eluted from renal tissues of IgA

nephropathy patients also exhibits a galactose defi-

ciency in the O-linked glycans in the hinge-region.

The serum level of IgA1-containing circulating

immune complexes is elevated in patients with IgA

nephropathy. These complexes contain galactose-

deficient IgA1 (Gd-IgA1) bound by IgG and/or

IgA antibodies. Recently, we have shown that the

IgG auto-antibodies that recognize glycan-contain-

ing epitopes on Gd-IgA1 exhibit unique features in

the complementarity-determining region 3 of the

variable region of their heavy chains 13). Further-

more, the serum levels of IgG auto-antibodies

specific for Gd-IgA1 correlated with disease

severity, as assessed by the magnitude of proteinu-

ria. However, the serum levels of Gd-IgA1-contain-

ing circulating immune complexes may differ

widely among IgA nephropathy patients. Further-

more, some IgA nephropathy patients do not show

glomerular deposition of IgG, but rather only IgA.

Therefore, it is difficult to explain the pathogenesis

of IgA nephropathy by an elevated serum level of

glycan-specific antibodies of only the IgG isotype.

These latter features may be explained by our

observation that some patients with IgA nephrop-

athy have complexes generated by glycan-specific

antibodies of the IgA1 isotype. Whereas the serum

levels of IgA, Gd-IgA1, and glycan-specific IgG are

higher in patients with IgA nephropathy compared

with healthy controls, the levels of these parame-

ters have not been systematically studied in

patients with other kidney diseases with clinical

features similar to those of IgA nephropathy.

Therefore, we examined the prevalence of elevated

serum levels of IgA, Gd-IgA1, and glycan-specific

IgG and IgA in IgA nephropathy patients and a

large cohort of CKD patients to assess the utility of

these biomarkers for the non-invasive diagnosis of

IgA nephropathy. It was revealed that this panel of

biomarkers is helpful in differentiating patients

with IgA nephropathy from patients with other

glomerular diseases. Yanagawa and Suzuki et al. 14)

compared the serum levels of IgA, IgG, Gd-IgA1,

Gd-IgA1-specific IgG, and Gd-IgA1-specific IgA in

135 IgA nephropathy patients, 79 patients with

non-IgA nephropathy CKD, and 106 healthy

controls. Serum was collected at the time of renal

biopsy from all IgA nephropathy and non-IgA

nephropathy CKD patients. Each serum marker

was significantly elevated in IgA nephropathy

patients compared with non-IgA nephropathy

CKD patients (p<0.001) and healthy controls (p<

0.001). While 41% of IgA nephropathy patients

had elevated serum Gd-IgA1 levels, 91% of these

patients exhibited Gd-IgA1-specific IgG levels

above the 90th percentile for healthy controls

(sensitivity 89%, specificity 92%). Although up to

25% of non-IgA nephropathy CKD patients, partic-

ularly those with immune-mediated glomerular

diseases including lupus nephritis, also had an

elevated serum levels of Gd-IgA1-specific IgG,

most IgA nephropathy patients had elevated levels

of Gd-IgA1-specific antibodies of both isotypes.

Serum levels of Gd-IgA1-specific IgG were associ-

ated with renal histological grading. Furthermore,

there was a trend toward higher serum levels of

Gd-IgA1-specific IgG in IgA nephropathy patients

with at least moderate proteinuria (more than 1.0

g/g Cr), compared with the patients with less

proteinuria. In conclusion, serum levels of Gd-

IgA1-specific antibodies are elevated in most IgA

nephropathy patients, and their assessment,

together with serum levels of Gd-IgA1, improves

the specificity of the assays. It appears that a panel

of serum biomarkers may be helpful in differentiat-

ing IgA nephropathy from other glomerular

diseases 14).

Peritoneal injury in peritoneal dialysis (PD)

1. New biomarkers using peritoneal fluid

・Pentraxin 3 (PTX3)

PD is one effective treatment for ESKD patients.


261

However, it is well known that peritonitis and/or

bioincompatible peritoneal dialysate may play an

important role in the development of peritoneal

fibrosis. These pathological alterations of the

peritoneal membrane in long-term PD patients may

progress to EPS, i.e. a serious complication in PD

patients (Figure-4). Changes of peritoneal solute

transport in long-term PD patients often results

from an increased vascular surface area with

vasculopathy. Angiogenesis and vasculopathy in

the peritoneum may play an important role in the

regulation of water and solute transportation in the

peritoneum. However, the relationship between

vascular changes and the development of peritoneal

fibrosis is still obscure. Simple sclerosis consists of a

thin layer of submesothelial sclerotic tissues in PD

patients. EPS was characterized by the thickening

sclerotic tissues involving vascular alterations in PD

patients.

It is well-known that biocompatible peritoneal

dialysate may play a central role in the develop-

ment of preritoneal fibrosis. Peritoneal inflammation

continues even after the cessation of peritoneal

dialysate stimulation. It is important to establish a

definition of persistent inflammation in the perito-

neal cavity at the cessation of PD. Pentraxin 3

(PTX3) is characterized as a member of the long

pentraxin superfamily. It shares the C-terminal

pentraxin domain with short pentraxins such as

CRP and serum amyloid P components, but differs

in terms of the presence of an unrelated long

N-terminal domain, cellular source, and regulatory

mechanism. PTX3 is synthesized locally at the

inflammatory site from various kinds of cells,

including endothelial cells, smooth muscular cells,

and fibroblasts 15). Kanda and Hamada et al. 16) deter-

mined whether PTX3 in the peritoneal effluent

(PE) may be a new biomarker in PD patients.

PTX3 in serum, PE, and peritoneal specimens were

obtained from 50 patients with ESKD in our

hospital. Samples of 19 patients were obtained at the

initiation of PD and those of 31 patients at the

cessation of PD. PTX3, high-sensitivity CRP, matrix

metalloproteinase-2 (MMP-2), and IL-6 were ana-

lyzed. An immunohistological examination using an

anti-PTX3 antiserum was also performed. Expres-

sions of PTX3 were observed in the endothelial

cells, fibroblasts, and mesothelial cells in the peri-

toneum. The PTX3 level in PE at the cessation of

PD was significantly higher than that at the

initiation of PD. Effluent PTX3 levels in patients

with a history of peritonitis or a PD duration of

more than 8 years were significantly higher than

those in patients without peritonitis or in patients

with a PD duration of less than 8 years. The PTX3

level was significantly correlated with MMP-2 and

IL-6 levels in the PE, as well as the thickness of the

submesothelial compact (SMC) zone and the vas-

culopathy. It appears that PTX3 may be a new

biomarker of peritoneal inflammation and progres-

sive fibrosis 16).

Acknowledgements

A part of the manuscript was presented at the

Farewell Lectures by Departing Professors in

March 24, 2015 17). I wish to thank my colleagues for

supporting me throughout the years in the Division

of Nephrology, Department of Internal Medicine,

Juntendo University Faculty of Medicine, Tokyo,

Japan.

References

1) Japanese Society for Dialysis Therapy: An overview ofregular dialysis treatment in Japan as of Dec. 31, 2013(in Japanese).

2) Macisaac RJ, Ekici EI, Jerums G: Markers of and riskfactors for the development and progression of diabetickidney disease. Am J Kidney Dis, 2014; 63 (supple 2) :S39-S62.

3) Horikoshi S, Higurashi A, Kaneko E, et al: A newscreening method for proteinuria using Erythrosin B andan automated analyzer̶rapid, sensitive and inexpensive


262

Figure-4 Histopathological characteristics in a patient withperitoneal fibrosis

Loss of mesothelial cells and submesothelial fibrosis are observed

in peritoneal tissues (Masson trichrome staining).

determination. Clin Chim Acta, 2012; 11: 1087-1091.4) Horikoshi S, Okuda M, Nishimura E, et al: Usefulness of

HPLC assay for early detection of microalbuminuria inchronic kidney diease. J Clin Lab Anal, 2013; 27: 333-338.

5) Tashiro K, Koyanagi I, Saitoh A, et al: Urinary levels ofmonocyte chemoattractant protein-1 (MCP-1) and inte-leukin-8 (IL-8), and renal injuries in patients with type2 diabetic nephropathy. J Clin Lab Anal, 2002; 16: 1-4.

6) Tashiro K, Koyanagi I, Ohara I, et al: Levels of urinarymetalloproteinase-9 (MMP-9) and renal injuries inpatients with type 2 diabetic nephropathy. J Clin LabAnal, 2004; 18: 206-210.

7) Murakoshi M, Tanimoto M, Gohda T, et al: Mindin: anovel marker for podocyte injury in diabetic nephrop-athy. Nephrol Dial Transplant, 2011; 26: 2153-2160.

8) Gohda T, Tomino Y: A paradigm shift for the concept ofdiabetic nephropathy. Juntendo Medical Journal, 2014;60: 293-299.

9) Gohda T, Tomino Y: Novel biomarkers for the progres-sion of diabetic nephropathy: soluble TNF receptors.Curr Diab Rep, DOI: 10.1007/s11892-013-0385-9.

10) Niewcza MA, Gohda T, Skupien J, et al: Circulating TNFreceptors 1 and 2 predict ESRD in type 2 diabetes. J AmSoc Nephrol, 2011; 23: 507-515.

11) Nakayama K, Ohsawa I, Maeda-Ohtani A, Murakoshi M,

Horikoshi S, Tomino Y: Prediction of diagnosis of immu-noglobulin A nephropathy prior to renal biopsy andcorrelation with urinary sediment findings and prognosticgrading. J Clin Lab Anal, 2008; 22: 114-118.

12) Novak J, Moldoveanu Z, Julian BA, et al: Aberrantglycosylation of IgA1 and anti-glycan antibodies in IgAnephropathy: role of mucosal immune system. AdvOtorhinolaryngol, 2011; 72: 60-63.

13) Suzuki H, Fan R, Zhang Z, et al: Aberrantly glycosylatedIgA1 in IgA nephropathy is recognized by IgG anti-bodies with restricted heterogeneity. J Clin Invest, 2009;119: 1668-1677.

14) Yanagawa H, Suzuki H, Suzuki Y, et al: A panel of serumbiomarkers differentiates IgA nephropathy from otherrenal diseases. PLoS One, 2014; 9: e98081.

15) Carlanda C, Bottazzi B, Bastone A, Mantovani A: Pen-traxin at the crossroads between innate immunity,inflammation, matrix deposition, and female fertility. AnnRev Immunol, 2005; 23: 337-366.

16) Kanda R, Hamada C, Kaneko K, et al: Pentraxin 3 as anew biomarker of peritoneal injury in peritoneal dialysispatients. J Art Organ, 2013; 16: 66-73.

17) Tomino Y: Pathogenesis and treatment of chronickidney disease: a review of our recent basic and clinicaldata. Kidney Blood Press Res, 2014; 39: 450-489.


263



Rehabilitation in Juntendo University: Past, Present and Future

MASANORI NAGAOKA＊

＊Department of Rehabilitation Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan

In my final lecture, I have looked back the history of rehabilitation service in Juntendo Hospital. Rehabilitation

service was started as early as 1947, and was subordinated under the Department of Orthopedic Surgery. In 1972,

the then Professor of Neurology started another physiotherapy room mainly for neurological diseases. The

Department of Rehabilitation Medicine was inaugurated in 2003 and I became head of the department. At that

time, Juntendo Hospital had already enjoyed therapist-centered service for 56 years. One of my objectives was to

build a sound cooperation between their service and the new physician-centered service. The other objective was

to establish the attitude among all therapists to generate evidence in rehabilitation service. After my eleven yearsʼ

work in Juntendo, I have noticed that the demand for rehabilitation service is increasing steadily for patients with

many diseases other than neurological disorders. In 2015, we are engaging in many multi-disciplinary activities in

our hospital, such as participation in the skeletal related events (SRE) team, rehabilitation for pediatric patients,

and rehabilitation for cardiac patients. Along with the advance in medicine, rehabilitation physicians and

therapists need to continue to make efforts to develop and establish novel therapeutic skills in cooperation with

each specialist in medicine. When I review the history and the trend of rehabilitation service in Juntendo, it is

obvious that our task is to provide rehabilitation service to meet the growing demands from different medical

specialties.

Key words: rehabilitation, history, physician, therapist, multi-disciplinary team

Preface

In my final lecture, I will talk about the history of

rehabilitation service in Juntendo University. The

history of rehabilitation, particularly its general

aspect, is actually very vast and it is beyond my role

to review it all in this lecture. During the long

history of Juntendo Hospital since its inauguration

in 1838, there was no official record of rehabilitation

up to the end of the Second World War. Therefore, I

will try to base my lecture on Juntendo-shi (the

official history of Juntendo University) and the

experience I gained throughout my professional life

as a medical student, neurologist and rehabilitation

doctor.

Education of rehabilitation in the 1970s

The first memory of rehabilitation came from the

classroom. In Juntendo University, students had

taken rehabilitation for a course credit. A part-time

lecturer Dr. Satoshi Ueda from Tokyo University

taught us. He was one of the founding members of

the Japanese Association of Rehabilitation Medicine

(JARM). The photograph in Figure-1 is repro-

duced from his textbook published in 1971. His

lecture was obligatory, but I thought it was elective

because only a small number of students attended.

Regarding this vague memory on rehabilitation, I

can remember several words related to different

methods of treatment, such as physiotherapy,

occupational therapy, and physical medicine. When

I re-read this book now, I note that the important

264

Masanori Nagaoka

Department of Rehabilitation Medicine, Juntendo University Graduate School of Medicine




〔Received June 11, 2015〕

knowledge of disability was not written yet. The

idea of disability model, which was shown in the

International Classification of Impairments, Disabil-

ities and Handicaps (ICIDH), was regarded as a

revolutionary shift from the traditional medical

model aiming at curing. This concept was proposed

only around 1980.

Another memory of rehabilitation comes frommy

clinical training during the last medical school

years, so-called“polyclinic”. During the course of

orthopedic surgery, the then associate professor Dr.

Yasuo Yamauchi taught us about Milwaukee brace

for idiopathic scoliosis in adolescents at the outpa-

tient clinic. I recall that the room for rehabilitation

service was located next to the outpatient clinic.

The rehabilitation service provided was mainly

physical medicine, such as thermotherapy and

electrotherapy, apart from massage. One impres-

sive subject Dr. Yamauchi taught us was the

usefulness of the Krukenberg surgery for hand

amputees (Figure-2). This operation has some

advantages. For example, the pincer-like stump of

the reconstructed limb has sensation and is

functionally useful for handling objects, although

the appearance is not necessarily desirable. Now

when we look back the Krukenberg operation from

the viewpoint of rehabilitation, we should say that it

is a functionally valuable option as a biomechanical

approach. When I gave a short speech in Hiroshima

in 2013 on the occasion of a Juntendo University

alumni reunion, I was reminiscing about my first

encounter with the Krukenberg operation in my

medical school days, without knowing that Dr. Shuji

Nakamura who worked with Dr. Yamauchi on that

operation was also in the reunion. He later kindly

sent me a reprint of his publication.

As a neurologist

After I graduated from university, I decided to

learn neurology in Professor Narabayashiʼs depart-

ment (Figure-3). I was interested in brain and

nervous function. The then associate professor Dr.


265

Figure-1 Textbook recommended for medical students,written by Dr. Ueda in 1971

Figure-2 The article reporting the Krukenberg operationReproduced from reference 3.

Figure-3 Photograph of late Professor Hirotaro Narabaya-shi

From the graduation album of Juntendo University, School of

Medicine (1974). Reproduced from reference 4.

Keizo Hirayama had just published a textbook on

neurological semiology. He showed us very elegant

methods of neurological examinations in the clinic.

For me, semiology or symptomatology was very

impressive, because lesions in the nervous system

manifest as various changes in function, i.e. dysfunc-

tion. I was interested in investigating these

dysfunctions by neurophysiological techniques as

one of Dr. Narabayashiʼs pupils.

In the department of neurology, I had seen many

patients with various diseases such as Parkinsonʼs

disease, myasthenia gravis, dystonia, spinocerebel-

lar degeneration, polymyositis and infectious dis-

eases. At that time, only few treatments for

neurological diseases were available. For the well

known Parkinson disease, the introduction of

L-dopa and its combination with decarboxylase

inhibitor was expected to bring substantial benefit

for the patients. However, this therapy turned out

to be a useful treatment option, but a cure for the

disease remained to be discovered.

In 1974 when I started my career as a neurologist,

the department of neurology already provided

specific rehabilitation service for patients with

neurological diseases on the same floor as the

neurology ward. In 1972, two years before I joined

the department, Professor Narabayashi had organ-

ized the initiation of this service. I do not know the

reason why Juntendo had decided to start a

different discipline of physiotherapy, other than the

traditional physiotherapy unit belonging to the

department of orthopedic surgery. It is possible that

since Professor Narabayashi traveled worldwide to

present his works on Parkinsonʼs disease, he

perhaps noted the novel technique of neurodevelop-

mental therapy, the so-called Bobath approach for

neurological diseases. This possibility is supported

by his paper that appeared in Juntendo Medical

Journal in 1969. He invited Miss Seybold from West

Germany to visit our university, and she was a pupil

of Mrs. Bobath who invented this technique.

Since 1972, we had two different disciplines of

physiotherapy in Juntendo, a traditional physiother-

apy discipline that mainly used massage and

physical medicine, and the other that used the

neurodevelopmental approach.

During my training in neurology, I could remem-

ber always having a feeling of regret to my patients

because we were not able to cure their diseases,

particularly many of the degenerative diseases.

When I was a young neurologist, I did not consider

rehabilitation service as an important medical

prescription. Perhaps even with rehabilitation

service using the neurodevelopmental approach, I

always had a kind of feeling of regret and said sorry

to all my neurological patients.

Transfer from neurology to rehabilitation medicine

In 1992, I moved to Narugo in Miyagi prefecture,

where the rehabilitation facility of Tohoku Univer-

sity (Figure-4) was located at that time, to learn

rehabilitation medicine from Professor Ryuichi

Nakamura (Figure-5). He was a friend of Professor

Narabayashi and I was invited to join his group in

Narugo for a few years.

My work in Narugo was only for two years, but

the experience had great impact on me and it was

Nagaoka M: Past, present, and future of rehabilitation

266

Figure-4 Photograph of Narugo Branch Hospital of TohokuUniversity School of Medicine, drawn by Mrs.Sonoko SatoReproduced from reference 5.

Figure-5 Photograph of Professor Ryuichi NakamuraReproduced from reference 6.

the most condensed time in my life. When I arrived

at Narugo and started my training as a rehabilita-

tion doctor, I thought I could work as an established

rehabilitation doctor because the diagnoses of

diseases such as stroke, Parkinsonʼs disease and

spinocerebellar degeneration were rather familiar

to me, as I saw these patients as a neurologist in

Tokyo. However, the unforgettable experience and

lessons that I had learned in Narugo was the basic

attitude of rehabilitation physicians toward the

patients.“He will be able to go around the rice

fields,”I explained during one conference session to

explain the goal of a 3-month rehabilitation pro-

gram for my stroke patient. I thought that“go

around”meant just to walk on a flat road, without

considering the detailed implications. But, one of the

experienced occupational therapists pointed out

that these words meant the ability of walking even

on a narrow ridge between rice fields. I then

realized that the words that I used in the conference

to describe the rehabilitation goal did not properly

expressed my thought. In this manner, I have

learned that understanding of patientsʼ life is

important and indispensable for a rehabilitation

physician.

From Narugo to Tokorozawa

In 1994, I moved to Tokorozawa to work in the

National Rehabilitation Center for the Disabled

(NRCD, Figure-6) with Professor Nakamura. He

had already moved there several months earlier as

the director of the hospital of NRCD, and later he

became President of NRCD. NRCD is the largest

institute in Japan for physically disabled persons

including those who are blind and deaf. NRCD has

many therapists and facilities for rehabilitation

service, including pre-vocational and vocational

training. There I saw not only stroke patients, but

also patients with spinal cord injuries and those

with higher brain injuries. Technically, therapists in

NRCD did not belong to a particular discipline. At

the NRCD, I have learned the vast system of health

and welfare service, particularly for rehabilitation in

Japan, because NRCD is an organization closer to

the Ministry of Health, Labor and Welfare than

ordinary hospitals. I worked on several clinical

studies and basic research with my colleagues Drs.

Naoyuki Kakuda and Takako Miwa.

As one of the clinical research conducted in


267

Figure-6 Aerial photograph of National RehabilitationCenter for the Disabled in 2003

Figure-7 Data of eye position recordingThe patient has unilateral spatial neglect on the right side. His viewing point was deviated to the left originally (before), but this deviation

was relieved and neglect was improved by the cold air irrigation (30 deg C) of the right ear by air-caloric test. Reproduced from reference 7.

Before After vestibular stimulation by air caloric test

NRCD, the findings of visual agnosia and unilateral

spatial neglect using the ISCAN, an equipment

designed to record the gaze point, are shown in

Figure-7.

The other important experience was rehabilita-

tion for patients with higher cerebral dysfunction.

In 2001, NRCD conducted a model project for

patients with such disturbances. I joined the project

and participated in the nationwide survey. As one of

the activities related to this project, we translated

and published the monograph written by Dr.

George Prigatano.

Back to Juntendo

In 2003 Professor Yoshikuni Mizuno of the

Department of Neurology who headed the selection

committee for professor of the department of

rehabilitation, gave me an opportunity to work in

Juntendo again.

I set myself two objectives for working in

Juntendo. One was to build a sound cooperation

between the conventional therapist-centered serv-

ice and the new physician-centered service of

intervention. The other was to establish the attitude

among all therapists to generate evidence in

rehabilitation service.

Since then, I have worked in the university

hospital as the chief rehabilitation doctor; and

taught medical students, student nurses and

students of health and sports sciences. I have also

conducted several clinical studies in Juntendo to

show evidence for the effectiveness of the rehabili-

tation service performed in Juntendo Hospital. One

example of such evidence is the success in the

treatment of abnormal posture known as dropped

head syndrome.

Looking back my eleven years at Juntendo

After eleven years of working at Juntendo, I am

going to leave my current position. I will review the


268

Table-1 Chronological table of rehabilitation service in Juntendo University

Name of facility In Charge

Mr. Shimada

Prof. Haneda（Orthop）

Mr. Hamaura

Shinbo, Sato PTs

Hamaura PT retired

Prof. Yamauchi（Orthop）

Prof. KatayamaProf. SatoShinbo PT headedProf. MiyanoProf. Nagaoka

Shinbo PT retired

Athletes, Cardiac

From all fields,Neurological, Skeletal,Spinal, Pediatric,Respiratory,Cardiac,Cancer, Disuse

Hamaura PTProf. Aoki

Diagnosis and methods

Neurological diseases

Neurodevelopmentalapproach

PoliomyelitisLCCScoliosisFractureStroke

MassagePhysical medicineExercise

1947

1950

1951

1967

1968

1972

1991

19941996199820022003

2006

2014

2015

Massage room

Massage room for Orthopedicsurgery

Belongs to Hospital service

Located next to outpatient clinic ofOrthopedic surgery

Branch physiotherapy room in newhospital building

Dept of rehabilitation medicine

Outpatient clinic started

Grand rehabilitation room inbuilding B

Rehabilitation rooms distributed inseveral places

New Hospital building No.1New Hospital building No.119931993

of

Shin

PPSPPr

trend of rehabilitation service in Juntendo Hospital,

and if possible foresee the future of rehabilitation.

Table-1 shows the development of rehabilitation

service in Juntendo in chronological order.

The rehabilitation service was started as early as

1947. The facility for such service was named“the

massage room”. When Juntendo had the first

professor in orthopedic surgery, Professor Haneda

put the massage room under his control, and the

room was run by the department of orthopedic

surgery. Twenty years later, this facility was placed

in the central service section of the hospital, but was

chaired by professors of orthopedic surgery.

Regarding therapists, Mr. Hamaura was qualified as

a certified physiotherapist in 1967. During this era,

the major diseases were stroke, fractures, polio and

luxatio coxae congenita (LCC). The techniques

used were massage, physical medicine and thera-

peutic exercise. Around 1972, when I was a medical

student visiting the orthopedic outpatient clinic as a

part of my clinical clerkship (polyclinic), rehabilita-

tion service had already started, some twenty-five

years ago.

On the other hand, the first professor of neuro-

logy Dr. Narabayashi was keen to develop a better

technique for neurological disorders. He probably

thought that traditional physiotherapy using both

massage and physical medicine was not sufficient

for the treatment of neurological diseases. There-

fore, he invited Miss Seybold, a pupil of the inventor

Bertha Bobath, to the department as already men-

tioned above.

The reason for the installation of the second

physiotherapy room is shown in one of his paper

published in Juntendo Medical Journal in 1969.

After his attendance to the 11th World Congress of

Rehabilitation International held at Dublin, Ireland,

on 14-19th of September 1969, he wrote about the

attitude for specialists engaged in rehabilitation. His

comments are summarized as follows.

・Introduction of a deductive approach for cerebral

palsy, i.e. proprioceptive neuromuscular facilita-

tion (PNF) and Bobath method are necessary

also for neurological diseases.

・In order to establish a specific rehabilitative

intervention as standard treatment for a given

disease, an attitude of deductive thinking is

imperative for understanding the pathophysio-

logical phenomenon and methods of treatment.

When I started my career in neurology in 1974, a

branch of the physiotherapy room which aimed at

patients with neurological disorders was estab-

lished in the new hospital building. In this branch

physiotherapy room, neurodevelopmental approach

was solely used. If we consider the number of thera-

pists in a particular discipline as an indicator of

balance of power between two different disciplines,

the number of therapists in neurodevelopment

approach increased, and the other group decreased

steadily. When I returned to Juntendo in 2003, I

noticed that therapists were nearly completely

replaced by the Bobath group, and only one

therapist remained in the traditional group.

Contribution to rehabilitation medicine by

other specialties

Professor Yoshinosuke Fukuchi and his group in

respiratory medicine published the manual of

respiratory rehabilitation for COPD patients. Later,

Professor Atsushi Amano of cardiovascular surgery

asked us to intensify rehabilitation service for

postoperative patients in the intensive care unit.

During the same period, Professor Akira Kurosawa

and his group published the effects of exercise

therapy for osteoarthrosis of knee. These develop-

ments indicate that requirement for rehabilitation

service is not restricted only to neurological

diseases. Furthermore, the rehabilitation division of

Juntendo Hospital, particularly the therapists, is

already facing difficult situations in rehabilitation

for patient diagnosed with cancer. One of the

reasons is that some surgeons are reluctant to share

the knowledge about the patientsʼ correct diagnoses

and prognoses with the patients themselves, their

families and other medical personnel. When a

therapist is asked to help a patient in walking and if

he has a metastatic lesion in the femoral bone, the

therapist tends to get into a dilemma of whether he

should tell the patient that walking is dangerous

due to the risk of pathological fracture.

Role of rehabilitation service

Considering these circumstances, I understand

that while neurological disorder is one of diseases

that require rehabilitation, the demand of rehabilita-

tion service for many patients with other diseases is


269

increasing steadily. Now we are treating patients

from all fields of medicine.

In 2015, therapists are engaging in many different

activities in our hospital (Table-2). As medical

service is divided into specialties, therapists need to

prepare to give specific service for individual

patients. Besides rehabilitation doctors and thera-

pists, we have to collaborate with these specialists

to develop and provide new service and explore the

novel findings during treatments. This approach is

shown schematically in Figure-8. We may have

good collaborations with many different fields in

medicine.

For children with orthopedic problems, Drs.

Tanaka and Sakamoto already run an outpatient

clinic. For metastatic bone diseases, Dr. Tatsuya

Takagi chairs regular multidisciplinary team con-

ferences with physiotherapist Eriko Kitahara to

manage skeletal related events (SRE). For cardiac

diseases, Professor Hiroyuki Daida and Dr. Kazu-

nori Shimada run cardiac rehabilitation in the Sport

Activity and Wellness Center. With pain clinic, we

hold regular meetings to discuss patients with

chronic pain.

When I review the history and the trend of

rehabilitation service in Juntendo, it is obvious that

the need for rehabilitation service is steadily

increasing. As for the technical issues, how young

therapists should be trained on basic skills for

handling patients is a fundamentally important

problem for senior therapists. Along with the

advance in medicine, therapists also are required to

update their medical knowledge and modify their

basic skills in line with the advance in medicine. As

specialists working in university hospitals, rehabili-


270

Category Activity

Orthopedic Shoe fitting

Prosthesis and orthosis

Skeletal related events (SRE) team

For children with orthopedic problems

Pediatrics Cerebral palsy

Cancer patients in pediatrics

Neurology Parkinsonʼs disease

Deep brain stimulation (DBS) team

Respiratory medicine Training course for COPD out-patients

Cardiac Intervention in ICU and patients withischemic heart disease

Pain control Physiotherapy for patients with chronicpain syndrome

Nutritional support team

Decubitus ulcer care team

Respiratory care team

Table-2 Different activities performed by the Division ofRehabilitation in Juntendo Hospital in cooperationwith other departments or as joint activities as amember of the multidisciplinary team

Figure-8 A Plan for Juntendo Rehabilitation Center for the 22th Century

Dr

To postgraduatecourse from differenthospitals

Nr

PTOT

STTrin－er

Etc

Dr

Nr

PTOT

STTrin－er

Etc

Dr

Cardiology

TrainingFunction ofHolistic Medicine

Make Evidence of Rehabilitationto Different Diseases

Rehabilitation Doctors＝Common Knowledge of Rehabilitation＋Specific Knowledge of Each Disease

Make Evidence of Rehabilitationfor Primary/Secondary Prevention

Respiratory medicineEducation System for Common Knowledge of RehabilitationEducation System for Common Knowledge of Rehabilitation

Neurology/Neurosurgery Orthopedic surgery

Nr

PTOT

STTrin－er

Etc

Cerebrovascular Locomotive Cardiovascular Pulmonary

Dr

Refresh Club

School for Healthand Sports

School for Health

School forDiabetes Mellitus

School for Obesity

New Hospital Building（B）

Appeal for Studentsand ParamedicalStaffs

・Specialists able to consider Human Function・Knowledge of different diseases

Nr

PT

Share Common Knowledgethrough Faculty Development

OT

JapanHeartClub

ST PediatricsMetabolism andendcrinology

PediatricsMetabolism andendcrinology

Trin－er

EtcExercise for Children of

Pediatric WardExercise for Children of

Pediatric Ward

Nr

OT

STTrin－er

Nr

PTOT

STTrin－er

Nr

PTOT

STTrin－er

Nr

OT

STTrin－er

PT PTOT〔Pediatric Disease〕

Cerebral palsySpina bifidaCancers

Extremely Low Birth Weight Infant

〔Pediatric Disease〕Cerebral palsySpina bifidaCancers

Extremely Low Birth Weight Infant

tation physicians and therapists need to continue to

make efforts to develop and establish novel

therapeutic skills.

Acknowledgement

Besides the doctors and therapists mentioned in

this article, I must express my gratitude for all

doctors, nurses, therapists, and workers in all the

hospitals in which I have worked up to this day. I

am in debt to physiotherapist Masatomi Sone for

compiling the chronological table. Finally I must

thank my family for their collaborations over the

years.

References

1) Juntendo, ed: Juntendo-shi, the second volume. Tokyo:

Juntendo, 1996.2) Satoshi U: Rehabilitation Medicine Illustrated. Tokyo:

University of Tokyo Press, 1971.3) Yamauchi Y, Nakamura S: Krukenberg operation for

forearm amputees. Japan Medical Journal, 1972; 2553.4) Graduation Album of Juntendo University, School of

Medicine, in 1974.5) The editorial board of the memorial book for 50 years

anniversary of Narugo branch hospital of TohokuUniversity: The commemorative book of Narugo branchhospital of Tohoku University School of Medicine for 50years since its foundation and closing. 1994.

6) The editorial board of the memorial book for 20 yearsanniversary of National Rehabilitation Center for Physi-cally disabled: The commemorative book of NationalRehabilitation Center for Physically disabled for 20 yearssince its foundation. 2000.

7) Miwa T, Nagaoka M, Hayashi H: Transient improve-ment of right visuo-spatial hemineglect by vestibularstimulation. JMDD, 1999; 9: 77-80.

8) Prigatano GP: Principles of Neuropsychological Rehabil-itation. Translated by Nakamura R, Amakusa B, et al,Tokyo: Ishiyaku-shuppan, 2002.


271



A Personal Research Chronicle for 41 Years at Juntendo University

TAKASHI UENO＊

＊Research Support Center, Juntendo University Graduate School of Medicine, Tokyo, Japan

From April 1974 through March 2015, I spent most of the time at the Department of Biochemistry to give

lectures of biochemistry to under graduate students of the Faculty of Medicine as well as to conduct basic

research. Here, I look back on my research life mainly in relation to peers of the department, intramural friends,

and extramural collaborators. The recollection covers three periods sequentially: the infancy of muscle research

(1974〜1985), the transition stage to study non-muscle cell motility (1985〜1995), and the developmental period

engaged in autophagy (1995〜2014).

Key words: myosin, sulfhydryl group, hepatocyte, phalloidin, autophagy

Start-up as a young instructor in the Department of

Biochemistry (from 1974 through 1985)

“Keiichi is so outstanding in physical chemistry

among you all. Yoh is very good at structural

biochemistry and enzymology. So, what is your

most favorite area of specialty?”

This was the question often asked by Takamitsu

Sekine when I had worked as an instructor during

1974 and 1987 at the Department of Biochemistry. I

started my career of education and research for

basic medicine at Juntendo University in April of

1974, after I graduated from the master course of

the University of Tokyo Graduate School of Science.

Takamitsu Sekine, the chairman of the Department

of Biochemistry, was one of renowned biochemists

working on muscle contraction in Japan (Figure-1,

a portrait). His main research subject was struc-

ture-function relationship of skeletal muscle myo-

sin. He was a talented researcher and specialized in

physicochemical approaches to analyze the move-

ments and conformation of protein molecules. He

discovered two important sulfhydryl groups (SH1

and SH2) that are located adjacent to the catalytic

site of myosin and essential for myosin ATPase

activity. He was so enthusiastic for investigating

how the two SH groups play roles in the hydrolyis

of ATP by myosin, and actin-myosin interaction.

For his research goal, he collaborated with Yuichi

Kanaoka, Hokkaido University, to develop many

SH-specific fluorescent modifiers (Sekine-Kanaoka

reagents), includingBIPM (N-[4-(2-Benzimidazolyl)

phenyl]maleimide), ANM(N-(1-anilinonaphthyl-4)

272

Takashi Ueno

Research Support Center, Juntendo University Graduate School of Medicine


TEL: +81-3-3813-3111 (ext. 3627, 3628) E-mail: [email protected]


〔Received May 7, 2015〕

Figure-1 Professor Takamitsu Sekine (photograph takenin 1985)

-maleimide), and DACM(N-(7-dimethylamino-4-

methylcoumarinyl)maleimide). Once the reagents

bound covalently to SH1 and SH2 residues, the

environmentally-sensitive fluorophores of the

reagents would provide valuable information on the

conformational changes and local fluctuation around

the sulfhydryl residues of myosin molecules. Also, it

had been demonstrated that the reactivity of these

reagents to myosin should be influenced by

conformational changes of myosin upon ATP

hydrolysis, Ca2+ binding, and the interaction with

actin.

Under Takamitsu Sekine, three professors, Tatsu-

hisa Yamashita (associate professor), Tsuneo Kame-

yama (assistant professor), and Masahiro Yama-

guchi (associate professor of the Faculty of the

Health and Sports Science) were managing the

department. Tatsuhisa Yamashita soon became

independent to have his own laboratory (Labora-

tory of Physiological Chemistry). There were many

young staff at age of 20ʼs〜30ʼs. Notably, many of

them were so capable and became professors of

important national or other private universities,

later. Takao Ohyashiki, who worked on muscle

troponin-tropomyosin, soon moved to Hokuriku

University and eventually assumed the presidency

of the university. Kenji Takamori earned his Ph.D.

degree by a study of chemical modification of SH1

with various maleimide derivatives. He went

abroad to Duke University to work on epidermal

sulfhydryl oxidase. After he came back to Juntendo

University, however, he shifted away from muscle

research to clinical research of dermatology. Years

later, he was promoted to the professor of Derma-

tology at Juntendo Urayasu Hospital and finally

became the director of the hospital. Tsuneyoshi

Horigome worked vigorously to determine the

primary structure (amino acid sequences) around

SH1 and SH2 residues. I still remember that he

always worked beside an amino-acid sequencer

equipped in our laboratory. In 1978, he gained a

position of professor at Niigata University. Keiichi

Yamamoto, an assistant professor, graduated from

the master course of the University of Tokyo

Graduate School of Arts and Sciences. Keiichi

Yamamoto extensively investigated the reactivity

of SH1 to DACM under various conditions and

succeeded in unraveling the spatial relationship

between SH1 and myosin light chains as well as

actin-binding site of myosin. He succeeded to

Koscack Maruyama, his former teacher to become a

full professor at Chiba University. Yoh Okamoto

joined our group in 1976 after he earned his Ph.D.

degree at Hokkaido University Graduate School of

Science. He initiated a new study on smooth muscle

myosin from chicken gizzards. Yoh Okamoto found

that reconstituted gizzard myosin with ANM-

labeled light chain was a useful tool to monitor ATP

binding to the catalytic site of myosin heavy chains.

In 1991, he acceded to a full professor of Muroran

Institute of Technology.

Personally, I owe quite a lot to Takamitsu Sekine,

Keiichi Yamamoto, and Yoh Okamoto. Although

Takamitsu Sekine was so busy in faculty adminis-

tration, he liked to have unscheduled discussions

with the staff about newly obtained experimental

data as well as recent papers published by other

groups. Sometimes, the discussion continued for one

hour or more. He always urged each of the staff to

promote his or her strong area of specialty to

become a distinguished researcher. He believed

that specialty was so important for a researcher to

accomplish oneʼs own goal. Indeed, the aforemen-

tioned questioning quoted in the opening paragraph

must be an expression of his belief. Keiichi

Yamamoto was a very smart scientist. He was so

clever to make up good experimental plans,

avoiding technical struggles and logical leaps.

Consequently, he could publish many articles

efficiently. I was deeply impressed with his swift

performance and progresses in his bench work. Yoh

Okamoto was also a very skilful experimenter. He

was so patient and could concentrate on his

experiments in the cold room even for all day. He

had excellent potency for protein chemistry, which

could finally produce fruitful findings.

Surrounded by these superb peers, I felt a bit

awkward and dithered over what to do for my own

study for several months. Then, I finally decided not

to work on skeletal muscle proteins. Instead, I

focused my subject on sarcoplasmic reticulum

(SR). Active Ca2+ transport by SR contributes to

decreasing Ca2+ concentration in the muscle cyto-

plasm to below 10−7 M, which elicits muscle relax-

ation. Ca2+ release from SR contributes to a raise in

cytoplasmic Ca2+ concentration (10−5 〜10−6 M),

eliciting contraction (sliding between thin and thick

filaments). At that time, the mechanism of Ca2+


273

release from SR was completely unknown. I wanted

to explore conditions or some chemical or electric

stimuli to release Ca2+ from SR vesicles that had

been preloaded with 45Ca. However, it became soon

evident that my expectation was too optimistic. Due

to an unusually high permeability of SR membrane

to Na+, K+, and Cl−, manipulations using Na+

-specific or K+-specific ionophores had no effect on

accumulated 45Ca2+ in SR vesicles. I spent as long as

four years until I published the first paper.

However, the issue of this paper was not Ca2+

release, but active Ca2+ transport into SR vesicles. In

the end, I could somehow earn my Ph. D. by a

finding that H+ was released from SR as a counter

cation in exchange for Ca2+. In the meantime, I got

an opportunity to go abroad. I repeatedly consulted

with Takamistu Sekine as well as other staff and we

decided to shift our focus on more wishful field of

research. I finally applied for Edward D. Korn at the

National Heart, Lung, and Blood Institute (NHLBI)

at Bethesda, Maryland. E. D. Korn used to work as a

section chief in Wayne Kiellyʼ s laboratory where

Takamitsu Sekine also studied for two years in

early 1960s. E. D. Korn was a pioneering scientist

working on non-muscle contractile and cytoskeletal

proteins of soil amoeba, Acanthamoeba castellanii.

He was renowned for his discovery of sin-

gle-headed myosin I. Fortunately, I succeeded in

acquiring a funding from the Foundation of

Muscular Dystrophy and from September 1983

through August 1985, I worked under E. D. Korn on

amoeba cytoskeleton and discovered a new

55kDa-dimer actin-binding protein. I was also

fortunate to collaborate with other postdoctoral

fellows to characterize a myosin I from cellular

slime mold, Dictyostelium discoideum. Two years of

life at the NHLBI made me feel more confident in

my ability to face unknown challenges of biochemis-

try.

Unexpected switch from cell motility to autophagy

(1985〜1994)

After I returned from NHLBI to Juntendo

University, I set out my new study on cytoskeletons

of non-muscle cells. At the time, Sumio Watanabe

(the Division of Gastroenterology) who went

abroad to Toronto University also returned home.

At Toronto University, he had studied cell biology

of bile secretion from hepatocytes into bile canali-

culi. He demonstrated that microfilaments sur-

rounding bile canaliculi were essential for normal

secretion of bile from hepatocytes. The conclusion

was supported by a finding that phalloidin, which

had been known to immobilize filamentous actin to

inhibit dynamic function of microfilaments, effec-

tively inhibited bile secretion. He believed that for

better understanding the mechanism of bile secre-

tion, the role of myosin should be clarified. As a

consequence, I began to collaborate with Sumio

Watanabe and purified myosin from rabbit hepato-

cytes and rat hepatocytes, respectively. I character-

ized purified myosin biochemically and raised

antibodies to myosin. Immunofluorescent histo-

chemistry using these antibodies clearly showed

that myosin in hepatocytes was colocalized with

actin along bile canaliculi and became more

concentrated upon in vivo phalloidin administration.

The data strongly suggested that actomyosin

contractility along bile canaliculi was essential for

normal bile secretion. While I concentrated on the

new project of hepatocyte myosin, Takamitsu

Sekine retired from the professor of biochemistry at

March 1987. One year after, the Department of

Biochemistry received Eiki Kominami from Toku-

shima University as a successor to Takamitsu

Sekine. Eiki Kominami had studied lysosomal

cathepsins, a group of cysteine proteinases, and

their intrinsic inhibitors, cystatins. His specialty was

completely different from muscle biochemistry. As

often happened in the chairman replacement, it

seemed not easy for the staff of the department to

adapt themselves to a completely new research

field. One hope was that Eiki Kominami was also

eager to shift or extend his research scope.

One day I talked to Eiki Kominami about my

inexplicable experimental data. I found that livers

from phalloidin-administered rats manifested hepa-

tomegaly, containing more protein per liver than

normal control rats. Also, more myosin and actin

were found accumulated in liver from phalloidin-

administered rats compared with control rats. Eiki

Kominami watched my data carefully and sug-

gested to me“Ueno-san, maybe autophagy in the

liver is inhibited by phalloidin?”The term

“autophagy”was completely new to me and I asked

Eiki Kominami to explain more details about

autophagy.

Ueno: Research on muscle, cell motility, and autophagy

274

Autophagy is a large-scale degradative system,

by which cellular constituents, including cell

organelles and cytosolic proteins, are broken down

via the lysosomes. Autophagy functions constitu-

tively, but about two- to three-fold enhanced under

nutrient-deprivation as well as under stress condi-

tions. Autophagy initiates with the formation of

smooth limiting membrane, which extends and

sequester surrounding cytoplasm in the lumen to

form a double-membraned autophagosome (Fig-

ure-2). Then, autophagosome fuses with the

lysosome to mature into autolysosome. Sequestered

cytoplasmic components are degraded by lysosomal

hydrolases to amino acids, fatty acids, sugars, etc.

One of most exciting issues in the study of

autophagy was the origin of autophagosome

membrane. It had been long argued whether

autophagosomal membrane derives from preexist-

ing membranes such as ER and Golgi, or is

generated de novo. Furthermore, because autopha-

gosome specifically fuses with lysosome, it was

postulated that autophagosomal membrane should

possess a unique, intrinsic membrane protein(s).

During 1980s, Eiki Kominami attempted to purify

autophagsomes from rat liver, but he found that it

was too difficult. Instead, he and other groups took

notice of leupeptin-induced autolysosomes. Leupep-

tin is a specific inhibitor for cathepsins B, L, and H.

When administered into rats or mice in vivo,

leupeptin inhibits lysosomal proteolysis profoundly,

but degradation of lipids and sugars proceeds

normally. As a result, swollen autolysosomes with

sequestered proteins in the lumen become dense.

These denser autolysosomes can be purified from

other organelles and cell membranes by Percoll

gradient centrifugation. Advised by Eiki Kominami,

I attempted to separate autolysosomes using

Percoll gradient centrifugation and found out that

phalloidin inhibited hepatic autophagy effectively

through its effect on microfilaments. The work was

published in FEBS Journal (European Journal of

Biochemistry) as my first article for autophagy

study 1) and I could switch my project smoothly

from cell motility (bile secretion) to autophagy.

Next, based on the hypothesis that the denser

autolysosomes still retain autophagosomal mem-

brane marker (s), I concentrated on the compre-

hensive analyses of polypeptides of autolysosomal

membranes purified from rat liver to look for

presumptive autophagosome marker protein. At

that time, LC mass spectrometer affording

high-throughput analyses was not yet available. I

consulted with Kimie Murayama and Reiko Mineki

at the Research Support Center of Graduate School

of Medicine. There was a high-performance protein

sequencer produced by Hewlett Packard Co. So, I

collaborated with them and separated purified

autolysosomal membranes using two-dimensional

SDS polyacrylamide gel electrophoresis and made

thorough analysis of N-terminal 10 amino acid

sequences of each protein spot using the protein

sequencer. Actually, it was really painstaking work.

Many of the amino acid sequences determined

indicated that they were known proteins of ER

lumenal and membrane proteins, Golgi, or plasma

membrane proteins. Sometimes, no amino acid

sequences could be determined with separated

polypeptides. Those polypeptides might be likely

attributed to membrane-attached cytosolic pro-

teins with blocked N-terminus. After some twists

and turns, however, I could find a few polypeptides,

of which N-terminal amino acid sequences had not

been identified at the time. Based on the data, I

asked Kazumi Ishidoh, a colleague of my laboratory

to clone these“new”proteins. Surprisingly, three

polypeptides of different amino acid sequences

could be aligned to a single protein that had been

cloned a few months before as betaine-homocys-

teine S-methyltransferase (BHMT) by other

group. BHMT is a cytosolic protein highly

expressed in liver and its expression is upregulated


275

Figure-2 Controversy over the origin of autophagosomeIn response to nutrient starvation, limiting membrane elongates

and surrounds cell organelles such as mitochondria and other

cytoplasmic proteins into its lumen to form double-membraned

autophagosome. Autophagosome then fuses with the lysosome

and matures into autolysosome. The origin of autophagosomal

membrane has been long argued and finally demonstrated as de

novo formed membrane (phagophore).

ER, Golgi, or phagophore

limitingmembrane autophagosome autolysosome

lysosome

by fasting. Now, it became evident that BHMT

was not an intrinsic membrane protein of

autophagosomes but a substrate of autophagy

sequestered in autolysosomes. Hence, my efforts for

identifying an integral autophagosmal membrane

marker were failed. Years later, Yukiko Kabeya,

Tamotsu Yoshimori, and others published an

article, in which they demonstrated that LC3 was

truly an intrinsic autophagosomal membrane

protein 2). I collaborated with them and could

somehow contributed to that paper: LC3 was

certainly identified in my autolysosomal mem-

branes. The reason for the inability to detect LC3 in

my approaches is probably attributable to

extremely low expression of LC3. In 2007, research-

ers from University of Oslo extensively analyzed

isolated autophagosomes by MALDI-TOF mass

spectrometric analyses. However, they could not

identify LC3. LC3 could be detected only in western

blotting, but not in silver stained two-dimensional

SDS gels.

Autophagy study in post ATG era (1995〜2014)

One day in January 1995, I got a phone call from

Yoshinori Ohsumi. At that time, he was an associate

professor of the University of Tokyo Faculty of

Arts and Sciences. Two years before (1993), he

published a historic article, in which he identified 15

genes essential to autophagy in yeast Saccharomy-

ces cerevisiae. There was no idea what the products

of these genes (later named ATG genes) do.

Indeed, none of these ATG genes had been

previously described. Yoshinori Ohsumi wanted to

call for Japanese researchers of autophagy to join

his group to explore molecular mechanism of

autophagy based on new, molecular and genetic

approaches. I well remember and will never forget

his phone call. It sounded like a heaven-sent

opportunity to me who had struggled for years in

comprehensive amino acid sequence analyses. Eiki

Kominami and I completely welcomed Ohsumiʼ s

proposal. On October 20, 1995, Yoshinori Ohsumi

organized a symposium on autophagy titled“Intra-

cellular degradation: a new expansion of autophagy

research”at the annual meeting of the Japanese

Society for Cell Biology held at Tohoku University.

Five Japanese groups and two overseas groups

gathered and presented their findings. It was a very

small assembly, but became a true edge of

prosperous“postATG era”of autophagy research

not only in Japan but also in all over the world.

One year later, Yoshinori Ohsumi was promoted

to a full professor at the National Institute of Basic

Biology. Tamotsu Yoshimori and Noboru Mizu-

shima joined Ohsumiʼ s laboratory as an associate


276

Figure-3 Central role of Atg7 in autophagosome formation through its activation of Atg12 and Atg8Two modifier proteins, Atg12 and Atg8, are activated by Atg7 (E1-like enzyme) to form substrate-enzyme complex via thioester bond

(orange circle). Next, Atg12 is transferred to Atg10, an E2-like enzyme, and subsequently conjugated with Atg5 to form Atg12-Atg5

conjugate via isopeptide bond (red bar). Atg12-Atg5 conjugate binds Atg16 to forms a Atg12-Atg5 • Atg16 cluster and the cluster

assembles to form a precursor of autophagosomal structure (PAS). Meanwhile, Atg8 activated by Atg7, is transferred to Atg3, and finally

conjugated with phosphatidyletanolamine (PE) to form Atg8-PE via amide bond (red bar). Atg8 is a soluble, small protein, but Atg8-PE

formed behaves as an integral membrane protein, recruiting phospholipids to form autophagosomes, along with PAS.

Atg12 Atg12

Atg10 Atg5

Atg8Atg8

Atg3

thioester bond

isopeptide or amide bond

Atg8；LC3, GABARAP, GATE－16（mammals）

PE

Atg8

Atg7

Atg7

Atg5

PAS

autophagosome

Atg16Atg12 Atg12

professor and a postdoctoral fellow, respectively.

Eiki Kominami and I frequently visited the National

Institute of Basic Biology to consult with Yoshinori

Ohsumi how the collaboration between the two

groups should be achieved and finally reached an

agreement that we were to focus on Atg7. To

promote investigations on our side fruitfully, Isei

Tanida, one of Yoshinori Ohsumiʼ s disciples was

recruited to our laboratory in April of 1997. Two

years later, Masaaki Komatsu, a post-graduate

student, joined our group. First, Isei Tanida and

Masaaki Komatsu decided to focus on yeast Atg7

and then extend their investigations to mammalian

cell system. Meanwhile, Noboru Mizushima,

Tamotsu Yoshimori, and Yoshinori Ohsumi discov-

ered that yeast Atg7 functions as a unique

protein-activating enzyme (E1) essential for auto-

phagy-specific two conjugation reactions: one for

Atg12-Atg5 conjugation and the other for Atg8-

phosphatidylethanoamine (PE) conjugation 3) (Fig-

ure-3). Since the two conjugation reactions were

indispensable for autophagosome formation (Fig-

ure-3), it turned out that Atg7 played a central role

in autophagy. As for our group, Masaaki Komatsu

and Isei Tanida demonstrated that Atg7 forms a

homodimer with its carboxyl-terminal domain that

was also essential for its catalytic activity. In view of

the importance of Atg7, we decided to adopt two

strategies: exploring three mammalian Atg8 homo-

logues and generation of Atg7-knockout mice.

1. Three mammalian Atg8 homologues and their

tissue-specific roles in mammalian autophagy

There is only one Atg8 in yeast, Saccharomyces

cerevisiae. In contrast, three mammalian Atg8

homologues had been reported until 2001: LC3,

GABARAP, and GATE-16. LC3 (MAP-LC3) is a

small subunit of microtubule-associated protein

IA/IB light chain 3. GABARAP is a GABAA

receptor-associated protein. GATE-16 is a Golgi-

associated ATPase enhancer-16kDa. Isei Tanida

demonstrated that all the three homologues func-

tion as substrates for Atg7 (E1) and Atg3 (E3),

respectively. It was reported by Yukiko Kabeya et

al. that all the three homologues were recruited to

autophagosomes when overexpressed in cultured

cells. Zvulun Elazar and his group claimed that LC3

functions in autophagy promptly after nutrient

starvation, but GABARAP and GATE-16 were

recruited to autophagosomes under prolonged

starvation. We raised antibodies to each homologue

and found that the expression of the three

homologues were diverse among different tissues 4).

We therefore postulated that depending on differ-

ent tissue cells the contribution of the three

homologues to autophagosome formation might be

different. To examine this possibility further, Isei

Tanida generated GFP-GABARAP and GFP-

GATE-16 transgenic mice. These mice are useful to

detect GABARAP- or GATE-16-positive autopha-

gosomes as green fluorescent spots in fluorescence

histochemistry as well as biochemical analysis. We

found that LC3 was expressed universally through-

out all tissues, but expression of GABARAP and

GATE-16 were divergent in different tissues.

Further examination revealed that GFP-

GABARAP was highly expressed in podocytes in

kidney glomeruli, so we collaborated with Katsu-

hiko Asanuma (Division of Nephrology) and his

colleagues. However, strong support for the partici-

pation of GABARAP in autophagosome formation

in podocytes, has not been available so far. More

recently, it has been shown that GFP-GABARAP is

more abundantly expressed in axonal initial

segments (ALIS), whereas expression of LC3 is

relatively poor. More extensive look at autophago-

somes in ALIS is plausible to understand participa-

tion of GABARAP in neuronal autophagy. At

present, there is no evidence for positive role of

GATE-16 in tissue type-specific autophagosome

formation.

2. Emerging field of autophagy brought by tissue

specific Atg7-deficient mice

In 2001, Masaaki Komatsu graduated from the

Graduate School of Medicine and earned his Ph.D.

degree by his study on yeast Atg7. He began to

master experimental procedures for generating

Atg7-knockout mice under Tomoki Chiba and Keiji

Tanaka, Tokyo Metropolitan Institute of Medical

Science. At that time, Noboru Mizushima, who had

acceded to a project leader of the same institute,

showed in precedent experiments that Atg5-null

mice were born apparently in normal shape, but die

within 24 hours of birth. So, Masaaki Komatsu

changed his strategy to concentrate on tissue-

specific Atg7-deficient mice. He first generated

liver-specific Atg7-deficient mice and published his


277

work in Journal of Cell Biology in 2005 5). From 2005

through 2015 Masaaki Komatsu has further

accomplished unparalleled achievement in this field,

including brain-specific autophagy deficiency at the

Tokyo Metropolitan Institute of Medical Science 6).

Among many findings, the discovery of a selective

autophagy substrate, p62, may be most important.

Basically, autophagy is responsible for non-selec-

tive turnover of cell constituents. Masaaki Komatsu

and Yoshinobu Ichimura demonstrated that p62

binds to polyubiquitylated proteins, on one hand

and interacts specifically with LC3 at its LRS (LC3

recognition sequence), on the other. Hence, p62

with bound polyubiquitylated polypeptides is spe-

cifically incorporated into autophagosomal lumen

and degraded selectively. Importantly, Masaaki

Komatsu found that accumulated p62 under autoph-

agy-deficiency functions as a hub that modifies

diverse cellular signaling pathways, including

aggregate formation, transcription regulation,

tumorigenesis, inflammation, metabolism, etc.

These important discoveries about pathological

outcome have never been brought without his

extraordinary efforts and challenging aspiration. In

last part of this essay, I briefly mention about two

original findings obtained by our group using

knockout mice generated by him.

Autophagic degradation is accelerated under

nutrient-deprivation and released amino acids,

fatty acids, and sugars are thought to be recycled

metabolically. Concerning liver autophagy, it was

postulated that glucogenic amino acids produced

via autophagy might be converted to glucose via

gluconeogenesis to maintain blood glucose. Junji

Ezaki, an associate professor, energetically under-

took this issue. He struggled back and forth, but

finally established an experimental regimen to

induce autophagy in the liver of individual mouse

simultaneously. He could indicate that amino acids

released via liver autophagy of wild-type mice

significantly contribute to maintaining normal level

of blood glucose under starvation condition (Fig-

ure-4A). In contrast, blood glucose became more

rapidly reduced under starvation in mice with

Atg7-deficient livers 7). For that study, Junji Ezaki

frequently worked through the night and made a

superhuman effort in his experiments.

Contribution of autophagy in skeletal muscles has

long been a subject of controversy. Many studies

have thrown light on an indispensable role of

proteasomes in the turnover of skeletal muscle

proteins. Norihiko Furuya generated skeletal

muscle-specific Atg7-deficient mice and exten-

sively studied contribution of autophagy to dener-

vation-induced skeletal muscle atrophy. He eventu-

ally found that oxidative stress was increased due

to accumulation of functionally defective mitochon-

dria in Atg7-deficient soleus muscle. The enhanced

oxidative stress in turn inhibited proteasome

activation (biosynthesis), which eventually lead to

suppression of muscle degradation (= atrophy). In

contrast, defective mitochondria in wild-type soleus

muscles was immediately cleared by mitochon-

dria-specific autophagy (mitophagy) without elicit-

ing oxidative stress, which resulted in proteasome

activation and normal atrophy (Figure-4B) 8).

Thus, autophagy is not involved in direct break-

down of muscle proteins in the disuse atrophy.


278

Figure-4 A.Metabolic contribution of liver autophagyB. Contribution of autophagy to denervation-induced atrophy of soleus muscles

A. Starved liver

Blood glucose

Normal

gluconeogenesis

Low Atg7－KO

cell proteins

autophagy

amino acids

Wild typeglucose

denervation inactive mitochondria

oxidative stress

Atg7－KO

inactive mitochondria

autophagy

degradation

proteasome synthesis

myofibril degradation（atrophy）

Wild type

B. Denervated soleus muscle

Conclusion with special thanks

Throughout 41 years of my life at Juntendo

University, I somehow overcame a couple of

turning points to continue my study and served a

term as a researcher of basic medicine. One and

only reason for this continuation is that I have had

good colleagues and friends. They gave me timely

advices about what I should do in the next step of

my study and, in some situation, financial supports.

Although I do not mention in the foregoing text, I

would like to extend a special thank to Yasuo

Uchiyama, who have collaborated with Eiki Komi-

nami for nearly 40 years. I met with him for the first

time when Eiki Kominami assumed the professor of

Biochemistry in 1988. Since then, he has consis-

tently supported our study: molecular pathological

analyses of neuronal ceroid lipofuscinosis (Batten

disease) and molecular cell biology of autophagy

using knockout mice, in particular, brain-specific

Atg7-deficient mice. As an extramural collaborator,

he moved to Iwate Medical University, Osaka

University, but finally to Juntendo University as the

professor of Anatomy and Cell Biology. I owe him

not only my research achievement but also diverse

administrations at the Research Support Center.

References

1) Ueno T, Watanabe S, Hirose M, Namihisa T, KominamiE: Phalloidin-induced accumulation of myosin in rathepatocytes is caused by suppression of autolysosomeformation. Euro J Biochem, 1990; 190: 63-69.

2) Kabeya Y, Mizushima N, Ueno T, et al: LC3, amammalian homologue of yeast Apg8p, is localized inautophagosome membranes after processing. EMBO J,2000; 19: 5720-5728.

3) Mizushima N, Noda T, Yoshimori T, et al: A proteinconjugation system essential for autophagy. Nature,1998; 395: 395-398.

4) Tanida I, Ueno T, Kominami E: LC3 conjugation systemin mammalian autophagy. Int J Biochem Cell Biol, 2004;36: 2503-2518.

5) Komatsu M, Waguri S, Ueno T, et al: Impairment ofstarvation-induced and constitutive autophagy inAtg7-deficient mice. J Cell Biol, 2005; 169: 425-434.

6) Komatsu M, Waguri S, Chiba T, et al: Loss of autophagyin the central nervous system causes neurodegenerationin mice. Nature, 2006; 441: 880-884.

7) Ezaki J, Matsumoto N, Takeda-Ezaki M, et al: Liverautophagy contributes to the maintenance of bloodglucose and amino acid levels. Autophagy, 2011; 7: 727-736.

8) Furuya N, Ikeda S, Sato S, et al: PARKIN-mediatedmitochondrial clearance contributes to the proteasomeactivation during slow-twitch muscle atrophy viaNFE2L1 nuclear translocation. Autophagy, 2014; 10:631-641.


279



A Retrospective of My 40 Years of Research on Mosquito Ovarian Development;

Amino Acids, Not Solely an Element of Yolk Protein Synthesis,

But an Activating Factor of Oogenesis

KEIKICHI UCHIDA＊

＊Division of Biology, Department of General Education, Juntendo University Faculty of Medicine, Chiba, Japan

Most people know that mosquitoes bite us, and cause mild or sometimes severe itching, but it is not necessarily

common knowledge that only female mosquitoes suck blood to produce eggs for the next generation to succeed.

Unfortunately this insect does not produce just one batch of eggs, but bites again and again, and as is well known

they may transmit dangerous microorganisms from the previous host to the next host during the biting and

oogenesis cycle. Understanding the role of animal blood in mosquito oogenesis may help establish effective

methods to control this vector insect. Although the digestive products of the ingested blood are obviously

translated into nutritional materials in the developing oocyte, such as yolk proteins or lipids, we hypothesized that

animal blood may contain some special substances to activate mosquito ovarian development, since blood-feeding

is quite a unique behavior among insects. During 40 years of experiments from such a nutritional point of view,

however, it turned out to be rather simple; amino acids resulting from blood protein digestion have the potential to

activate and promote the whole process of mosquito ovarian development when the nutrients are gradually and

continuously supplied into the hemolymph of females. In this review, we will describe the studies used to reach this

conclusion.

Key words: mosquito, ovary, development, amino acids, infusion

Introduction

In nature, most insects feed on plant nectars for

survival and to produce eggs. In contrast, mosqui-

toes and other bloodsucking flies have developed

the special skill through long evolutionary path-

ways to pierce the animal skin and suck blood.

While they may risk injury and even death by such

close proximity to their unwilling hosts, the benefit

of blood sucking is quite clear; the rich proteins in

the blood allow females to produce enormously

large numbers of eggs compared with nectar

feeding. In Japan, for instance, Culex pipiens moles-

tus (Japanese name“Chikaieka”, roughly meaning

“underground house mosquito”) are able to make

the first batch of mature eggs after adult emer-

gence without taking a blood meal; this reproduc-

tive potential is called“autogenous”. For the first

batch of egg production, the females of this species

utilize the nutrients which they have deposited

during the larval stage and transferred to the adult

stage. This nutrient storage may run out due to the

first batch of egg production, as they need to suck

blood for the second and subsequent batches of egg

production. The second and later batches of eggs,

produced“anautogenously”by blood meals, con-

tain three to four times the number of eggs as in the

first batch of autogenously-produced eggs. Such

“fecundity”due to blood feeding is one of the main

reasons why it is difficult to effectively control

mosquitoes.

Under the leadership of Dr. Teruhiko Hosoi, we

280

Keikichi Uchida

Division of Biology, Department of General Education, Juntendo University Faculty of Medicine

1-1 Hiraga Gakuendai, Inzai-shi, Chiba 270-1695, Japan



〔Received May 1, 2015〕

began experiments to clarify the relationship

between the blood meal and ovarian development.

We were concerned with the nutrients within

animal blood, especially whether the nutrients are

only elements for synthesis of proteins, mainly yolk,

or have some essential role(s) in activating and

regulating oogenesis.

Mosquito ovarian development by

feeding on protein food

Throughout our experiments, we used Culex

pipiens pallens mosquitoes (“Akaieka”in Japanese

derived from its body color). These mosquitoes are

night biters, and many people have had the bitter

experience of a midnight“buzz”at the ear and

followed by an annoying itch, while she hides as

soon as the light comes on in an attempt to kill her.

Before reporting our results, we will briefly

describe the digestive organs of mosquitoes.

Mosquitoes, or insects in general, have two diges-

tive organs, the midgut and the crop. The midgut is

a real digestive organ like our stomach, where the

blood is ingested directly. Dr. T. Hosoi found that

adenosine 5ʼ nucleotides in blood cells, such as AMP,

ADP, or ATP are a phargostimulant for female

mosquitoes to engorge blood into the midgut 1).

Production and secretion of digestive enzymes, and

absorption of resulting digestive products, occur in

the midgut. On the other hand, the crop is generally

a storage organ of sugar solutions such as plant

nectars. The inner wall is covered with wax and

does not allow movement of water molecules across

the wall so as to prevent radical changes of hemo-

lymph osmosis by water penetration from the

hemocoel to the crop inside. Crop-ingested nutri-

ents are gradually transferred into the midgut for

digestion.

To begin with, we fed female mosquitoes on blood

fractions or other proteins 2)-4). Protein solutions

mixed with AMP were introduced into the midgut,

while the same protein solutions mixed with sugar

were ingested into the crop. As is shown in Figure-

1, blood fractions or even non-blood proteins such

as egg albumin have the potential not only to

activate ovarian development but also to produce

mature eggs when introduced into the midgut,

while the same nutrients ingested into the crop had

only a small effect. At the time we started this

study, there were theories that some mechanical

stimulations are involved in oogenesis, such as

midgut or abdominal wall distention due to an

ingested blood meal. It was supposed that the

distention might stimulate the brain via the nervous

system to release oogenically essential hormone

(s). Although our results might have seemed to

support these ideas, both sugared blood plasma and

egg albumin, which fully expanded the abdominal

body wall by filling the crop, had little oogenic

effect, thus denying the involvement of abdominal

wall distention (Figure-1). A stimulative effect of

midgut distention alone could also be ruled out,

since AMP-containing saline solution without

proteins showed no positive effects (Figure-1).

As to the quite low effect of sugared meals, we

doubted that crop-ingested proteins could be

thoroughly digested, since in many fed females the

abdominal expansion soon returned to the unfed

level within 24 hours. It seemed rather likely that

the nutrients had been eliminated through the


281

whole blood

midgut

Females with activated ovaries（％）

midgut crop

Digestive organ where the food was ingested

midgut midgutcrop

plasma100

0

20

40

60

80

egg albumin AMPin saline

activated matured

Figure-1 Ovarian development in female Culex pipiens

pallens fed protein mealsFemales were fed on pig whole blood, pig blood plasma, egg

albumin (7.5% w/v), or saline containing 10−3 M AMP. The

blood plasma and egg albumin solutions were mixed with either

10−3 M AMP to introduce the meal into the midgut, or 0.5 M

sucrose to introduce the meals into the crop. The control meal of

saline containing AMP was ingested into the midgut. Fed females

were dissected 4 days later to check ovarian development. As the

criterion for the activation of ovarian development, ovaries

comprising follicles which developed beyond the following stage

through maturity were designated as“activated”; the follicles

had grown in length nearly double the resting stage follicles

before blood feeding, and the oocyte inside contained dense yolk.

The white bar shows the percentage of females with activated

ovaries, and the black bar shows that with matured eggs. Data are

taken from Hosoi et al. (1975), and Uchida and Suzuki (1981,

1982).

midgut into the excreta without digestion. To con-

firm this, females fed on sugared egg albumin

solution were individually kept in test tubes for 24

hours. Then the excreta adhering to the test tube

walls were analyzed on SDS-PAGE3)4). Figure-2A

clearly shows that in most of the fed females the

ingested egg albumin is eliminated without any

digestion. We noticed, however, that among those

fully-fed females, there was a small population of

individuals (less than 10% of the total) which

retained most of the ingested food in the crop even

24 hours after feeding and showed less excretion of

the proteins. Ovarian development occurred quite

frequently among these females (Figure-2B). To

our surprise, no sugar was detected in the excreta,

in either protein-eliminated or protein-digested

individuals, indicating that the crop is absolutely

specialized only for sugar digestion.

From these results, it was supposed that 1)

proteins which are able to activate oogenesis are

not limited to blood proteins, 2) abdominal disten-

tion is not involved in ovarian development, 3)

midgut distention itself is also not crucial for

oogenesis, but the organ should be essential for

efficient protein digestion, and 4) once digestion of

proteins occurs, whether ingested into the midgut

or into the crop, ovarian development follows.


feeding on amino acids

Since the resulting products of protein digestion

are amino acids, we naturally took our investiga-

tions to the next step to feed mosquitoes on amino

acids 5). As a meal, 17 kinds of amino acids, the

composition comparable to guinea pig blood pro-

teins, were dissolved in water to give a final

concentration of the total amino acids of 7.5%

(w/v). First, it turned out to be difficult to feed

females on this nutrient into the midgut, even with

AMP; including animal blood, liquids which mosqui-

toes usually ingest into the midgut are isotonic to

the hemolymph, and perhaps the amino acid

mixture was too strong and would have tasted

“unusual”for mosquitoes to drink into the midgut.

On the other hand, they fully ingested the same

amino acid mixture into the crop when mixed with

sugar. Our first supposition was that amino acids

once stored in the crop could be easily absorbed

during passage through the midgut, since amino

acids do not need protease digestion. Dissection of

amino acid-fed females, however, showed poor and

inconstant results. Although the follicles were

activated to develop or even developed to maturity

more frequently than the sugared protein meals,

Uchida: Mosquito oogenesis activation by amino acids

282

Figure-2 Relationship between food retention in the crop and its elimination, and ovarian development in female Culex pipiens

pallens fed on 7.5% (w/v) egg albumin with 0.5 M sucroseFed females were individually kept in test tubes for 24 hours. Excreta adhering to the inner wall of the test tube was washed and subjected to

eliminated protein analysis on SDS-PAGE. Eliminated protein was determined on a densitometer and the percentage of elimination to

ingestion was calculated. Fed females were dissected 4 days after feeding to check ovarian development. The criterion for the activation of

ovarian development is the same as shown in Figure-1.

The data here show only two extremes of the results; A) in most of the fed females expansion of the crop by ingested meal quickly

disappeared within 24 hours, and B) in only a few fed females the crop was still expanded by the meal even 24 hours after feeding. Apparently

the females which failed to retain the meal eliminated most of the ingested protein without digestion and also failed to develop the ovaries

(A). In contrast, the females which were fully retaining the protein solution showed lower amounts of elimination, and also developed the

ovaries (B). Modified from Uchida and Suzuki (1981,1982).

cropfood disappearedwithin 24 hr offeeding food fully

retained formore than24 hr afterfeeding

100A B

0

50

eliminated/ingested protein（％）


the percentage varied between trials. We then

measured the excretion of crop-introduced amino

acids individually as we had done with the protein

meals. To our surprise, amino acids were often

eliminated into the excreta without absorption,

while sugar was again absolutely absorbed (Fig-

ure-3A). As in the case of protein meals, ovarian

development occurred more frequently among

those females which absorbed amino acids effi-

ciently by retaining the liquid in the crop and

transferring it gradually into the midgut (Figure-

3B).

These protein and amino acid-feeding experi-

ments altogether indicated that when amino acids

are efficiently absorbed, irrespective of the diges-

tive organ to which the nutrients were ingested,

ovarian development could be activated.

Amino acid injection

Once amino acids are absorbed, it is expected

that free amino acid concentrations in the hemo-

lymph consequently increase. For the next step, we

tried to inject this nutrient directly into the

hemocoel so as to simulate the above physiological

change and also to avoid the involvement of the

digestive organs. After a great many attempts,

however, the results were rather disappointing

compared with the feeding experiments. Although

the follicles frequently started to develop, yolk

deposition in the oocyte was very scarce as opposed

to its dense accumulation after a blood meal, and

none of the follicles matured. The early question

was raised again; does a mechanical change of the

digestive organs, or the digestive organ itself play

some crucial role(s) in mosquito oogenesis?

Turning point

As is supposed, hemolymph amino acid concen-

tration increase due to blood meal digestion must be

very gradual. In contrast, amino acid injection

causes a subtle and abnormal increase in the

concentration, disturbing the normal hemolymph

osmosis. Our sugared meal experiments showed

that ovarian development does not necessarily

require a large amount of amino acids. As was

described above, fed-females with developed or


283

Figure-3 Relationship between food retention in the crop and its elimination, and ovarian development in female Culex pipiens

pallens fed on 7.5% (w/v) amino acid mixture with 0.5 M sucroseFed females were individually kept in test tubes for 24 hours. Excreta adhering to the inner wall of the test tube was washed and subjected to

eliminated amino acid analysis with the use of fluorescamine. Eliminated amino acids were designated as the percentage of elimination to

ingestion. Fed females were dissected 4 days after feeding to check ovarian development. The criterion for the activation of ovarian

development is the same as shown in Figure-1.

The data here show only two extremes of the results; A) expansion of the crop by an ingested meal quickly disappeared within 24 hours, and

B) the crop was still expanded by a meal even 24 hours after feeding. As in the case with crop-ingested egg albumin, the females which failed

to retain the meal eliminated most of the ingested amino acids without absorption and also failed to develop the ovaries (A). In contrast, the

females which were fully retaining the amino acid solution showed lower amounts of elimination, and also frequently developed the ovaries

(B). Modified from Uchida (1983).

cropfood disappearedwithin 24 hr offeeding food fully

retained formore than24 hr afterfeeding

100A B

0

50eliminated/ingested amino acids（％）


matured ovaries still retained much of the

crop-ingested liquid 24 hr after the feeding, indi-

cating that the amount of nutrients transferred and

digested in the midgut during that period was quite

small. Another difference is that in injections there

is no such additional and continuous supply as is

expected in gradual digestion of the blood meal. We

therefore felt that the failure of the injection

experiments did not necessarily deny the active

involvement of amino acids in oogenesis, and

planned to artificially introduce amino acids into the

hemocoel as gradually as possible.

First, we approached this problem with an easy

method. As is shown in Figure-4, a female was fixed

on her back upon a slide glass with wax. Then all

the legs were removed at the basal junction with

the body wall. As insects belong to the phylum

“arthropod”i.e.,“articulated or jointed legs”, their

legs are easily removed at each junction without

any severe damage. This procedure fortunately

leaves a tiny hole at the junction for the hemolymph

passage. When a small volume of amino acid

mixture solution is placed on the cut legs, the liquid

stays as a droplet, since the body wall is covered

with wax throughout and repels water.

The specimen was maintained in a humid

container to avoid evaporation of the liquid, and

dissected 3 days after the treatment. In some

specimens, the liquid was soon absorbed into the

hemocoel. The resulting abdominal expansion must

have been identical to the case of injection, and no

ovarian development occurred with these speci-

mens. On the other hand, in a few females the

volume of the droplet remained at almost the same

size as in the beginning, and among these individu-

als the follicles developed nearly to maturity. The

fact is that, a small amount of amino acids, which

was transferred into the hemocoel through the tiny

hole of the junctions at a very slow rate, induced

ovarian development.

At this stage, we could finally confirm with

confidence the active role of amino acids in mos-

quito oogenesis. Since the droplet experiment did

not exactly measure the incoming flow rate of

amino acids, we then tried in earnest to develop a

procedure for infusing an amino acid solution into

the hemocoel so as to simulate the natural amino

acid concentration increase after a blood meal.


infusion of amino acids

We designed the simulation experiment by

introducing an amino acid solution into the hemo-

coel by a microsyringe held on an infusion pump 6).

Mosquitoes were immobilized individually between

a sponge block and fine nylon mesh. After a fine

glass needle, which was fixed to the tip of a syringe

needle, was gently inserted into the thorax wall, the

amino acid mixture was gently introduced into the

hemocoel. First, an appropriate flow rate was

estimated; 0.166 μl/hr (=4 μl/24 hr) caused a slight

expansion of the abdomen 24 hours later. For safety,

all subsequent infusions were performed with a

flow rate of 0.083 μl/hr (= 2 μl/24 hr). At 4 days

after the start of infusion, examined females were

dissected to check ovarian development. To be

honest, in spite of the positive information from the

“droplet”trial, we were greatly concerned about

this dissection, considering the time, effort, and of

course money put into this project. It was with

great satisfaction that we found that the ovarian

follicles had not only started to develop but had also

reached maturation in many examined females.

From Figure-5A, follicle growth to maturation

seems to need an amino acid supply for more than

20 hours, but this infusion offers mosquitoes only

120 μg of amino acids. Also, since amino acids are

nutritional elements for yolk protein synthesis, it is


284

Figure-4 A droplet experimentA chilled and immobilized female was fixed on a slide glass with

melted paraffin. Then her six legs were removed at the junction

connecting with the thorax wall. Three microliters of 7.5% (w/v)

amino acid mixture solution was gently placed on the cut legs. The

specimen was kept in a glass chamber with a wet cotton pad to

keep the environment humid. The degree of the retention of the

droplet was observed daily and the specimen was dissected 3 days

later to check ovarian development.

quite reasonable from Figure-5B that the number

of matured eggs increased according to the length

of infusion periods, and the number for 48 hours

infusion nearly doubled that of 24 hours.

Concluding remarks

Amino acids are generally considered only as

products of protein digestion or as a nutritional

element for protein synthesis. We have been

concerned rather with the active role of amino acids

in mosquito oogenesis. Our results showed that

amino acids themselves have the potential to

initiate and promote ovarian development until

maturity. The potential, however, is very delicately

regulated; ovarian development occurs only when

amino acids are supplied into the hemolymph

gradually and continuously. Although we did not

mention in the above sections, infusion of an amino

acid mixture with one amino acid eliminated from

the basal mixture often failed to activate full ovarian

development. It is therefore certain that, not one or

a few special amino acids, but a balanced amino acid

combination is also crucial.

Such an ability of amino acids does not seem so

unusual. When a cell first emerged on the earth (in

other words, the birth of life), it is quite conceivable

that the cell needed to catch and evaluate much

information from the surrounding environment.

After the cell acquired the ability to make proteins

from amino acids, it was crucial to evaluate

available amino acids for protein synthesis. Of

course by now hormones have come to significantly

govern many processes of large molecule synthesis

in multicellular organisms. In mosquitoes, ovarian

ecdysteroidogenic hormone released from the brain

is essential for oogenesis, since blood-fed and

decapitated females do not show any sign of ovarian

development at all. The brain hormone then stimu-

lates the ovaries to release an ecdysteroid hormone,

which in turn activates the fat body to synthesize

vitellogenin 7). However, in the early stages of the

evolution of life, cells might have started to

synthesize large molecules when raw materials

were available, and a“gradual”increase of these

raw materials could have been a signal for cells to

proceed with synthesis, since a gradual increase

may indicate a continuous supply of the materials.

Endocrine systems might have been involved and

developed much later, essentially harmonizing well

with the nutrients. In fact, the ecdysteroid hormone

alone has little effect on mosquito ovarian develop-

ment when injected into unfed females. Using the

above-described apparatus, however, we found

that the hormone could induce ovarian develop-

ment up to maturation when infused with amino

acids 8).

Our experiments did not draw much attention

when published, but it is our pleasure that some

recent studies on TOR (target of rapamycin) have

quoted our reports 9) 10). Again emphasized there is

the close correlation between amino acids and


285

100A

B

20

10 20 30 40

activated

matured

50

40

60

80

100

20

3 6 8 10 14 16Hours of infusion

Hours of infusion

18 20 24 48

40

60

80


Number of matured follicles

Figure-5 Ovarian development induced by infusion of7.5% (w/v) amino acid mixture into the hemo-coel in female Culex pipiens pallens

The amino acid mixture was gently infused into the hemocoel

through a fine glass needle at a flow rate of 0.083 μl/hour (2.0

μl/day) for different periods of time. Females were then dissected

4-5 days after the start of the infusion to check ovarian

development (A) and also count matured eggs (B). The criterion

for the activation of ovarian development is the same as shown in

Figure-1. The white dots show the percentage of females with

activated ovaries and the black dots show the percentage of

females with matured eggs. Modified from Uchida et al. (1992)

cellular response to the nutrients; we believe that

the“cell-amino acid conversation”will be recog-

nized as an important process in many living

organisms.

Acknowledgement

We are most grateful to the following Juntendo

people for their contributions and help during our

studies;

Drs. Kimie Murayama and Tsutomu Fujimura

(Division of Proteomics and BioMolecular Science,

BioMedical Research Center), Dr. Noriko Shindo

(Division of Biochemical and Molecular Research,

BioMedical Research Center ), Mrs. Michio Murai

and Mitsutaka Yoshida (Division of Morphology

and Image Analysis, BioMedical Research Center),

Dr. Takashi Ueno (BioMedical Research Center),

and Dr. Masako Nishizuka (Division of Medical

Education). We also thank Drs. Daijiro Ohmori and

Fumiyuki Yamakura (Department Chemistry) for

their technical assistance and valuable discussions.

Also acknowledged is Dr. Joseph A. Gardner for his

critical manuscript review.

References

1) Hosoi T: Adenosine-5ʼ -phosphates as the stimulatingagent in blood for inducing gorging of the mosquito.

Nature, 1958; 181: 1664-1665.2) Hosoi T, Uchida K, Sato S, Matsumura O: Initiation of

egg development in the mosquito, Culex pipiens pallens,stimulated by diet amino acids. J Coll Arts Sci ChibaUniv, 1975; B-8: 73-91.

3) Uchida K, Suzuki K: Elimination of protein-food inges-ted into the crop, and failure of ovarian development infemale mosquitoes, Culex pipiens pallens. Physiol Ento-mol, 1981; 6: 445-450.

4) Uchida K, Suzuki K: Elimination of protein-food inges-ted into the crop, and failure of ovarian development infemale mosquitoes, Culex pipiens pallens. II. Effect ofsugar-free egg albumin. Physiol Entomol, 1982; 7: 227-230.

5) Uchida K: Retention and elimination of crop-ingestedamino acids and their relation to ovarian development infemale mosquitoes, Culex pipiens pallens. Comp BiochemPhysiol, 1983; 75A: 535-539.

6) Uchida K, Ohmori D, Yamakura F, Suzuki K: Mosquito(Culex pipiens pallens) egg development induced byinfusion of amino acids into the hemocoel. J InsectPhysiol, 1992; 38: 953-959.

7) Clements AN: Hormonal regulation of ovarian develop-ment in anautogenous mosquitoes. In: Clements AN.The Biology of Mosquitoes, Vol. 1. London: Chapmanand Hall, 1992: 380-407.

8) Uchida K, Ohmori D, Eshita Y, et al: Ovarian develop-ment induced in decapitated female Culex pipiens pallensmosquitoes by infusion of physiological quantities of20-hydroxyecdysone together with amino acids. J InsectPhysiol, 1998; 44: 525-528.

9) Attardo GM, Hansen IA, Raikhel AS: Nutritional regula-tion of vitellogenesis in mosquitoes: Implication foranautogeny. Insect Biochem Mol Biol, 2005; 35: 661-675.

10) Attardo GM, Hansen IA, Shiao S-H, Raikhel AS: Identi-fication of two cationic amino acid transporters requiredfor nutritional signaling during mosquito reproduction. JExp Biol, 2006; 209: 3071-3078.


286

Usefulness of BCSH Criteria for Diagnosing Japanese Polycythemia Vera

-Comparative Analysis with WHO 2008 Criteria-

YURIKO YAHATA＊, AKIHIKO GOTOH＊, NORIO KOMATSU＊

＊Department of Hematology, Juntendo University Faculty of Medicine, Tokyo, Japan

Objectives: The World Health Organization (WHO) classification (2008) is widely used to diagnose polycythemia vera (PV).

However, some patients clinically suspected of PV may not be definitely diagnosed because they do not have a high hemoglobin

(Hb) level, one of the main and essential diagnostic criteria, or because of the lack of or unfilled minor criteria such as bone

marrow biopsy, endogenous erythroid colonies, and serum erythropoietin. The British Committee for Standards in Haematology

(BCSH) employed hematocrit (Ht), but not Hb, as an indicator in the PV diagnostic guidelines. Furthermore, if the presence of

the JAK2 gene mutation is demonstrated, PV can be diagnosed with Ht only by BCSH. Therefore, we evaluated the usefulness of

BCSH criteria for diagnosing PV in Japanese patients.

Methods: We determined hematological and clinical differences in 99 patients who met the BCSH criteria (Group A) and 69 PV

patients who met the WHO criteria (Group B).

Results: All patients in Group B also met the BCSH criteria. Thirty patients in Group A (43%) did not fulfill the WHO criteria. No

significant differences were observed in white blood cell and platelet counts, serum erythropoietin levels, the JAK2V617F allele

burden, or the risk of thrombosis and transformation into myelofibrosis between Groups A and B.

Conclusions: PV cases diagnosed by the BCSH criteria showed the same clinical picture as those diagnosed by theWHO criteria.

In view of actual clinical settings, the diagnostic criteria of BCSH criteria may be useful for the diagnosis of PV in Japanese

patients.

Key words: myeloproliferative neoplasms (MPN), polycythemia vera (PV), JAK2 mutation, The British Committee for

Standards in Haematology (BCSH), The World Health Organization (WHO)

Introduction

Myeloproliferative neoplasm (MPN) is a neoplas-

tic disease characterized by an abnormal increase in

hematopoietic cells. Philadelphia chromosome (Ph)

-negative MPN, excluding chronic myeloid leuke-

mia, mainly includes polycythemia vera (PV),

essential thrombocythemia (ET), and primary

myelofibrosis (PMF). Previous studies reported

that the JAK2V617F gene mutation was frequently

detected in Ph-negative MPN cases in 2005 (>95%

in PV and 50-60% in ET and PMF) 1)-5). The

prognosis of patients with PV is greatly influenced

by thrombosis and leukemic transformation 6).

Therefore, PV should be managed in a manner that

depends on an early accurate diagnosis before the

development of complications.

PV is currently diagnosed using the WHO clas-

sification (2008) 7) which specifically employs two

main criteria: (1) evidence of either an increase in

hemoglobin (Hb) levels (male: >18.5 g/dl; female:

>16.5 g/dl) or the RBC count and (2) the presence

of either JAK2V617F or exon 12 mutations, and

three minor criteria: (1) findings of three types of

hyperplasia in bone marrow biopsy samples, (2)

low serum erythropoietin (EPO) levels, and (3) the

formation of endogenous erythroid colonies (EEC).

Of these, two main criteria and one minor criterion,

or first one of the two main criteria and two minor

criteria should be met for a definite PV diagnosis.

Hb levels have been employed in the WHO

classification as the main criterion reflecting red cell

287

Original Articles


Corresponding author: Norio Komatsu

Department of Hematology, Juntendo University Faculty of Medicine



〔Received Jan. 19, 2015〕〔Accepted Feb. 21, 2015〕

mass (RCM), which has traditionally been used as a

diagnostic criterion by the Polycythemia Vera

Study Group (PVSG) utilizing radioactive ele-

ments. However, it currently remains unclear

whether Hb can be used as a surrogate for RCM8) 9)

because the number of early PV cases may be

underestimated by the WHO Hb criteria, causing

diagnosis delays 8) 10) 11). A tissue diagnosis with a

bone marrow biopsy specimen has been used to

effectively diagnose PV 12). However, some patients

do not undergo bone marrow biopsies, and diagno-

ses may differ according to the pathologistsʼ skill

levels and expertise. Furthermore, the formation of

EEC, which is employed as a minor criterion in the

WHO classification, can only be examined in a small

number of facilities.

On this background, diagnostic criteria for PV

were proposed as convenient diagnostic criteria by

the British Committee for Standards in Haematol-

ogy (BCSH) of the United Kingdom in 2005 and

2007 9) 13). Since the JAK2 gene mutation is fre-

quently detected in PV, the BCSH guidelines

recommended that PV can be diagnosed based on

Ht levels (> 52% in males and > 48% in females) if

the presence of JAK2V617F or exon 12 gene

mutations can be demonstrated, and also that JAK2

gene mutation-negative cases can be diagnosed as

PV based on exclusion items, such as the absence of

splenomegaly and secondary polycythemia. Fur-

thermore, a bone marrow examination is not

necessarily required by the BCSH criteria.

The JAK2 gene mutation is included in both the

WHO and BCSH criteria for PV, and has become

essential in the diagnosis of PV. We previously

developed a JAK2V617F allele burden quantifica-

tion method (ABC-PCR method) using peripheral

blood 14). In the present study, we utilized this JAK2

mutation detection method and examined the

usefulness of the BCSH criteria for diagnosing PV in

Japanese patients.

Patients and Methods

1. Study population

A total of 194 patients from 20 facilities, for whom

consent was obtained after approval (No. 21,076)

by the Juntendo University Ethics Committee

between April 2010 and December 2013, were

included. Peripheral blood was collected from

patients to be used in the JAK2 gene analysis. The

following clinical data entered by the attending

physicians were collected: date of the first visit,

blood counts at the time of the diagnosis or sample

submission for a genetic analysis (WBC, differential

WBC, RBC, and platelet counts, Hb, Ht, serum EPO,

bone marrow biopsy, splenomegaly [palpation and

imaging (ultrasonography or computed tomogra-

phy (CT) ) ], and a history of thrombosis or prior

treatment until blood sample submission. Blood

count data collected at the first visit or diagnosis

were used. Bone marrow biopsies were histologi-

cally diagnosed in reference to pathologistsʼ findings

at each facility.

2. JAK2V617F mutation analysis

Five milliliters of peripheral blood was collected

from the patients, followed by DNA extraction from

the whole blood. The JAK2V617F allele burden was

quantified using the ABC-PCR method 14). An allele

burden of >10% was regarded as positive (sensitiv-

ity: 5-10%). Patients with cut-off values of approxi-

mately 10% were re-examined using the AS-qPCR

method.

3. JAK2 exon 12 mutation analysis

DNA was extracted from the EEC of

JAK2V617F-negative cases clinically suspected of

having PV, followed by an analysis for the exon 12

mutation 15).

4. Statistical analysis

All statistical analyses were performed by JMP®

10 (SAS Institute Inc., Cary, NC, USA). The level of

significance was two-sided p < 0.05. A t-test or

Fisherʼs exact test was used to compare the two

groups, depending on the type of data. After

grouping depending on the presence or absence of a

history of thrombosis, the odds ratio of thrombosis

was estimated using a logistic model including age,

sex, JAK2V617F allele burden, blood counts, EPO,

splenomegaly, and cardiovascular risk factors

(smoking, hypertension, dyslipidemia, and diabe-

tes) as explanatory variables. The final model was

selected using the minimum AICc criterion (AICc

is the finite corrected Akaikeʼ s information

criterion) 16).

Yahata, et al: BCSH criteria for diagnosing Japanese PV

288

Results

1. PV patient profiles

As shown in Table-1, 99 patients were diagnosed

with PV based on the criteria of the BCSH

guidelines (Group A) while 69 patients were diag-

nosed according to the WHO criteria (Group B). All

patients in Group B fit the PV BCSH criteria.

Although bone marrow biopsy is required for the

detection of hyperplasia 17) which is included in the

WHO minor criteria, it could not conducted in some

patients who had been administered an anti-plate-

let agent or were of an advanced age. In the present

study, bone marrow biopsy was not conducted in 20

out of 30 cases that met the PV criteria of the BCSH

criteria, but did not fulfill the WHO criteria. This

was one of the major reasons why patients having

both of the major criteria did not meet the WHO

criteria. Another main reason was the lack of serum

EPO data (Table-2). Figure-1 shows the schema of

Group A (BCSH (+)), Group B (BCSH (+)/WHO

(+)), and Group C ((BCSH (+)/WHO (−)).

The profiles of patients diagnosed by BCSH

(Group A, n=99) and WHO (Group B, n=69) were

compared (Table-1). As described above, all

patients in Group B met the diagnostic criteria of

the BCSH criteria, indicating that Group A con-

tained all the patients of Group B. No bias was noted

in sex or age distribution between these two

groups. No significant difference was noted not only

in blood test items (WBC counts, Hb, Ht, platelet

counts, or serum EPO), but also in the JAK2V617F


289

BCSH(A) A vs. B WHO 2008(B)

Number of patients(M : F) 99(46 : 53) - 69(31 : 38)

Age(years, mean±SD) 65.1±12.1(20-90) 0.9844 65.0±12.2(20-90)

RBC(104/μl, mean±SD) 704.6±95.2 0.2179 722.7±89.9

M 701.1±102.5 0.1743 732.6±93.2

F 707.7±89.2 0.7156 714.6±87.4

Hb(g/dl, mean±SD) 18.8±1.8(14.7-24.3) 0.1165 19.2±1.7(16.5-24.3)

M 19.3±1.6(16.9-24.3) 0.0464 20.0±1.4(18.7-24.3)

F 18.4±1.9(14.7-22.2) 0.5363 18.6±1.8(16.5-22.2)

Hematocrit(%, mean±SD) 58.2±5.4(48.1-72.7) 0.1128 59.5±5.3(52.6-72.7)

M 59.1±5.4(52.5-72.7) 0.0846 61.3±5.1(53.2-72.7)

F 57.9±5.3(48.1-70.5) 0.5072 58.1±5.0(50.8-70.5)

MCV(fl, mean±SD) 83.4±8.3 0.7720 83.0±7.6

M 85.3±8.1 0.6121 84.4±7.2

F 81.8±8.1 0.9078 81.9±7.7

WBC(103/μl, mean±SD) 15.1±7.3(5.19-53.0) 0.3818 14.2±6.1(5.19-33.9)

Platelets(104/μl, mean±SD) 52.4±24.4(11.4-181.5) 0.6131 50.4±25.0(11.4-181.5)

EPO(mU/ml, mean±SD) 8.0±2.8(n=76) 0.5199 7.7±2.6(n=66)

(1.0-14.8) (1.0-12.1)

JAK2V617F, N(%) 96(97.0%) - 66(95.7%)

Allele burden(%, mean±SD) 73.3±24.4 0.7138 71.6±25.8

(18.6-100) (18.6-100)

<50% 14(14.6%) - 10(15.1%)

50%≧ 82(85.4%) - 56(84.9%)

Exon 12, N(%) 3(3.0%) - 3(4.2%)

Splenomegaly, N(%) 46(46.5%) 0.6369 29(42.0%)

Thrombotic event, N(%) 20(20.2%) 1.0000 14(20.3%)

Episode N 25 - 18

Arterial 18(72.0%) - 11(61.1%)

Venous 7(28.0%) - 7(38.9%)

Smoking 16(18.2%)(n=88) 0.8294 10(16.4%)(n=61)

Table-1 Profiles of PV patients who met the diagnostic criteria of the BCSH criteria or WHO 2008 classification

allele burden between these groups (mean, Group

A: 73.3%, Group B: 71.6%). However, in the male

population, Hb levels were significantly lower in

Group A than in Group B (mean, Group A:

19.3g/dl, Group B: 20.0 g/dl). More than 80% of

cases in Groups A and B showed a ≧50%

JAK2V617F allele burden (mean, Group A: 85.4%,

Group B: 84.9%). Clinical findings revealed no

significant differences in the frequencies of spleno-

megaly and thrombosis (Table-1). Myelofibrosis

was not observed in patients who underwent bone

marrow biopsies (data not shown). Thus, no

significant differences were noted in clinical back-

grounds between patients who met the BCSH

criteria and those who met the WHO classification.

All three patients with the exon 12 mutation met

the WHO classification (Group B) and accounted

for 3.0% and 4.2% of Group A and Group B,

respectively. The frequency of the exon 12 muta-

tion was previously shown to be high in Asia 18), but

was similar to that reported in Europe and the

United States 19). These three patients had different

mutations 15), all of which had been reported

previously 19).

2. Occurrence of thrombosis

A history of thrombosis was observed in twenty

(20.2%) and fourteen patients (20.3%) in Group A

and Group B, respectively. Thus, there was no

significant difference in its frequency between the

two groups. This frequency was almost consistent

with the findings of previous foreign retrospective

studies on PV patients (16-38%) 20)-23).

The results of thrombosis based on the site of

onset are shown in Table-3. A previous study

reported that arterial thrombosis was commonly

observed in PV patients 21). Arterial thrombosis (18

cases, 72%) was also more common than venous

thrombosis (7 cases, 28%) in the present study.

The incidence of cerebral infarction was the highest

in patients with arterial thrombosis, stroke (14


290

WHO classification

major criteria minor criteria

Hb JAK2 mutation EPO pathological findings EEC

a(n=11) ○ ○ 8§/3¶ 2§/9¶ 11¶

b(n=9) 9§ ○ 9¶ 2§/7¶ 9¶

BCSH n=30 c(n=2) 2§ ○ ○ ○ 2¶

d(n=3) 3§ ○ 3¶ ○ 3¶

e(n=5) 5§ ○ ○ 1§/4¶ 5¶

Open circles: fulfilled the criteria, §: did not fulfill the criteria, ¶: not conducted.

Table-2 Detailed reasons why 30 patients did not meet WHO 2008 criteria

Figure-1 Relationship between BCSH-defined and WHO-defined PV patients

The schema of Group A (BCSH (+)), Group B (BCSH (+)/WHO

(+)), and Group C (BCSH (+), WHO (-)) are shown.

Group C：BCSH（＋）/WHO（－）

Group B：BCSH（＋）/WHO（＋）

Group A：BCSH（＋）

Thrombosis N(%) Male Female

Arterial Total 18 7 11

Stroke 14(56%) 4 10

AMI/AP 3(12%) 2 1

Splenic infarction 1(4%) 1 0

Venous Total 7 3 4

DVT 5(20%) 3 2

PE 1(4%) 0 1

HVT 1(4%) 0 1

AMI: acute myocardial infarction, AP: angina pectoris, DVT:

deep venous thrombosis, HVT: hepatic vein thrombosis, PE:

pulmonary embolism

Table-3 Thrombotic events

cases, 56%), followed by myocardial infarction or

angina, which required catheterization (3 cases,

12%), and then splenic infarction (1 case, 4%). The

incidence of leg vein thrombosis was the highest in

patients with venous thrombosis (5 cases, 20%),

followed by pulmonary infarction (1 case, 4%), and

then relatively rare hepatic vein thrombosis (1 case,

4%). No significant difference was observed in the

frequency of arterial or venous thrombosis between

Group A (n=25, 72.0% vs. 28.0%) and Group B (n

= 18, 61.1% vs. 38.9%)(p = 0.5205). When 99 PV

patients diagnosed by the BCSH criteria were

divided into two groups according to the occur-

rence of thrombosis, splenomegaly was strongly

associated with thrombosis (Table-4). No relation-

ship was observed against the JAK2V617F allele

burden, age, WBC, smoking, or hypertension as

variables (Table-4). AhighWBCcount (>15,000/μl)

and JAK2V617F allele burden (≧50%), which have

been identified as risk factors for thrombosis 24)-26),

were not significantly different in this analysis.

Consistent with previous findings in which patients

with MPN repeatedly developed thrombosis 23), five

out of 20 patients repeatedly developed thrombosis

in the present study.

Discussion

We recently defined cases clinically suspected of

having PV, with low Hb levels in spite of a high RBC

count, as“suspected PV.”The JAK2V617F allele

burdens of these cases were almost the same as

those of PV cases that met the WHO classification.

Among 40 suspected PV patients, 11 were diag-

nosed with PV according to the BCSH criteria 15). In

the present study, we compared hematological and

clinical aspects between patients who met the

BCSH criteria (Group A) and those who met the

WHO criteria (Group B), and found no significant

differences in clinical backgrounds between Group

A and Group B. In addition, the distribution of the

JAK2V617F allele burden was not significantly

different between these groups.

Barbui et al. defined PV cases with Hb levels that

were lower than the WHO criteria (males: < 18.5

g/dl; females: <16.5 g/dl) and whose bone marrow

biopsy met the pathological criteria as“masked PV”,

thereby emphasizing the importance of bone marrow

biopsy17). In our analysis, five of the 30 patients

diagnosed with PV by the BCSH criteria only whose

marrow biopsy findings corresponded to those of PV,

but did not meet the WHO criteria for Hb, were

diagnosed with masked PV (Table-2, column c; n=2,

column d; n=3). Thus, some patients with“masked

PV”were diagnosed with PV using the BSCH

diagnostic criteria of the BCSH criteria. Silver et al.

previously characterized“masked PV”patients as

follows; predominantly male, higher platelet counts,

and more severe BM reticulin fibrosis 12). Consistent

with these findings, the ratio of males to females in

our“masked PV”patients was 4 to 1, although the

number of patients was very small (n=5). However,

no significant difference was observed in platelet

counts between the five“masked PV”patients and

defined PV patients diagnosed by the WHO criteria

(mean±SD×104/μl; 43.6±9.9 vs 59.5±4.4)(p=

0.1544).

Although the exon 12 gene mutation was

detected at a low frequency (3 cases, 3%), as

previously reported abroad 19), some PV cases may

be overlooked unless the exon 12 mutation is

analyzed in JAK2V617F-negative cases; however,

all three patients with the exon 12 mutation met the

WHO criteria for Hb in the present study.

The causal relationship between thrombosis and

the JAK2V617F allele burden remains controver-

sial. Vannucchi et al. reported that cardiovascular

events may occur in patients with a > 75%

JAK2V617F allele burden 27). In the present study,

three patients with cardiovascular diseases had a >

75% JAK2V617F allele burden. Cerebral infarction

was the most common arterial thrombosis, while

DVT was the most common venous thrombosis,

which is consistent with previous findings 25). The

prevalence of risk factors for cardiovascular events

(smoking, hypertension, dyslipidemia, and diabetes

mellitus) was analyzed; however, these were not

recognized as risk factors for thrombosis (data not


291

χ2 p-value

Splenomegaly 6.81247929 0.0091

JAK2V617F allele burden 2.36317738 0.1242

Age 0.19852119 0.6559

WBC 0.81803507 0.3658

Smoking 0.81306578 0.3672

Hypertension 0.59577978 0.4402

Table-4 Multivariate analysis of risk factors for throm-botic events in Group A

shown), presumably because of the limited number

of patients. The odds ratio of thrombosis was only

significant for splenomegaly in a logistic model (p=

0.0091)(Table-3). Although this was inconsistent

with previous findings 24), this discrepancy may be

explained by differences in populations between

Japan and European countries. In consideration of

the similar frequencies (20%) of thrombosis

between Groups A and B, it may be beneficial to

select patients suspected of having PV using the

BCSH criteria for therapeutic interventions to

prevent thrombosis.

A recent study demonstrated that PV and ET

patients with a > 50% or increasing JAK2V617F

allele burden were both more likely to develop

myelofibrosis and thrombosis 26). Thus, the allele

burden should be measured over time, as well as at

the initial diagnosis. In addition, according to the

BCSH criteria, PV can only be diagnosed according

to the JAK2V617F mutation and Ht level, and a

pathological examination is not required. Thus,

mimic ET accompanied by thrombocytosis and

initial/pre-polycythemic PV may not be diagnosed

by the BCSH criteria in patients with Ht levels that

do not meet the diagnostic criteria 28). However, in

contrast to PV cases, most ET cases showed a <

50% JAK2V617F allele burden 29). Furthermore, ET

with a high allele burden is more likely to transit to

PV 29). Our method in which the allele burden was

combined with the BCSH criteria may be useful;

however, further studies are warranted.

In conclusion, PV cases diagnosed by the BCSH

criteria showed the same clinical picture as those

diagnosed by the WHO criteria. In view of actual

clinical settings, the diagnostic criteria of the BCSH

criteria may be useful for the diagnosis of PV in

Japanese patients.

Acknowledgments

We thank Dr. Ferit Acar for his critical reading of

this manuscript. We also thank Dr. Yasuo Aota for

his help in preparing the manuscript. We thank Joe

Matsuoka for his advice on statistics and Kyoko

Kubo, Kazuko Kawamura, and Megumi Hasegawa

for their secretarial assistance. We also acknowl-

edge the Laboratory of Molecular and Biochemical

Research, Research Support Center, Juntendo

University Graduate School of Medicine.

Financial disclosure

No financial relationships with financial interests

relating to the topic of this manuscript have been

declared.

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293

Diversity of Arterial Branches in the Crural and Foot Region as Correlated with

the Relative Thickness of the Fibular and Posterior Tibial Arteries

SHIKI MACHIDA＊1) 2), HIROYUKI KUDOH＊1), TATSUO SAKAI＊1)

＊1)Department of Anatomy and Life Structure, Juntendo University Faculty of Medicine, Tokyo, Japan, ＊2)Department of

Physical Therapy, College of Clinical Medicine and Welfare, Tokyo, Japan

Objective: We studied how the course and branching of peripheral arteries are influenced by the diversity of the proximal

arteries, taking examples in the leg and foot region.

Materials and methods: The arteries in the leg and foot was studied in 18 lower extremities of Japanese cadavers and their

diversity was correlated with the relative thickness of fibular and posterior tibial artery.

Results: The posterior tibial artery was dominant in 8 cases (PTAD) and the fibular artery was dominant in 10 cases (FAD).

The communicating branch between the two arteries was single in 7 cases and multiple in 11 cases. The perforating branch of the

fibular artery was large in 4 cases, medium in 6 cases, and small in 8 cases. The large perforating branch was found in FAD group,

and the small perforating branch was mainly found in PTAD group. The dorsalis pedis artery was formed mainly by the anterior

tibial artery, but by the perforating branch in the cases of thick perforating branches. The anterior lateral malleolar artery was

single in 10 cases and multiple in 8 cases. The number of dorsal roots of dorsal metatarsal arteries was 3.3 in the cases of thick

perforating branch, 2.2 in medium perforating branch, and 0.6 in small perforating branch.

Conclusions: The formation of the dorsalis pedis artery and the number of dorsal roots of the dorsal metatarsal arteries were

influenced by the thickness of the perforating branch and thus by the relative thickness of the fibular artery.

Key words: fibular artery, posterior tibial artery, anterior tibial artery, dorsalis pedis artery, dorsal metatarsal artery

Introduction

The arteries manifest significant diversity in the

dividing pattern and courses they take in the

human body. Arterial diversity has been the

concern of anatomists ever since the 19th centuries

when Quain 1) and Dubrueil 2) published mono-

graphs on arterial variation. Adachi 3) studied the

arterial variation in the various parts of the body

using Japanese cadavers and proposed a classifica-

tion of variations in specific parts of the body. In the

latter half of the 20th century, the arteries were

visualized by medical imaging technique, and

arterial variations were studied by radiologists.

Based on 675 anatomical and radiological studies in

the literature, Lippert and Pabst 4) published a

monumental monograph on arterial variation.

Anatomical studies of arterial variation have the

advantage of detailed analysis visualizing minute

arterial branches, but are time-consuming and

labor intensive making it difficult to do quantitative

analysis of large numbers of examples. On the other

hand, radiological studies facilitated the quantita-

tive analysis of large numbers of examples, but

were inadequate to observe minute arterial

branches.

The arteries in the extremities constitute a single

trunk in the proximal region, and divide into a few

parallel arteries in the peripheral regions. The fore-

arm contains the radial and ulnar arteries, whose

relative dominance was known to be variable, and

their relative dominance per se affected the

variation of the superficial and deep palmar arch in

the hand 5). Recently Serita et al. 6) studied the

arterial variations distributing the muscles around

the scapula, and clarified that the distribution

294

Original Articles


Corresponding author: Tatsuo Sakai

Department of Anatomy and Life Structure, Juntendo University Faculty of Medicine



〔Received Nov. 10, 2014〕〔Accepted Feb. 18, 2015〕

pattern was influenced by the variation of branch-

ing pattern of the origin of supplying arteries.

The arteries of the leg are unique in possessing

three major arteries in parallel, the anterior and

posterior tibial arteries and the fibular artery. After

the monumental study by Adachi 3), the studies of

arterial variation in the leg were followed by

Trotter 7) who reported the branching pattern of

the popliteal artery in American cadavers, and by

Kim and Orron 8) based on radiological observations.

Recently Kropman 9) summarized the branching

patterns of popliteal artery based on 7,671 examples

in four anatomical and eleven radiological studies in

the literature. However, these studies focused on

the branching patterns of the three major arteries

from the popliteal artery, and did not clarify the

relative dominance of these arteries and their

relation to the variations in their peripheral arteries.

In the present study we reported the variations

of the peripheral branches of three major arteries of

the leg, and clarified their relation to the relative

dominance of the three major arteries.

Materials and methods

In the present study, 18 lower extremities were

examined from Japanese adult cadavers (11 right legs

and 7 left legs; 6 males and 12 females; average age at

the time of death, 82.8 years; range 60-107 years)

dissected in the gross anatomy course at the Juntendo

University School of Medicine in the years 2011-2013.

Cadavers with significant arteriosclerosis or arterio-

stenosis were excluded. The popliteal arteries and its

three tributaries as well as their peripheral branches

were pursued in the leg and foot, and the anatomical

findings were recorded by photographs and sketches.

The images of the left side examples were reversed

for the convenience of analysis.

Results

At the lower end of the popliteal fossa, the

popliteal artery divided into the anterior and

posterior tibial arteries in the middle of the

popliteus muscle, with the latter sending off the

fibular artery just below the lower end of the

popliteus muscle. After entering the anterior

compartment through the supreme portion of the

crural interosseous membrane, the anterior tibial

artery descended along the medial surface of the

tibialis anterior muscle (Figure-1A, B). In the

posterior compartment of leg, the fibular and

posterior tibial arteries descended on the lateral and

medial side of the region deeper to the soleus

muscle, respectively (Figure-1C, D).

1. Arterial branches in the posterior compart-

ment of the leg

The posterior tibial artery and the fibular artery

were unequal in thickness, and in 8 cases the

posterior tibial artery was relatively thick (PTAD;

posterior tibial artery dominant) and in the other 10

cases the fibular artery was relatively thick (FAD;

fibular artery dominant).

The posterior tibial artery and the fibular artery

were connected by one or a few communicating

branches predominantly at the level of the lower

end of interosseous membrane of leg where the


295

Figure-1 Photographs and schematic drawings of thearteries in the right leg

The posterior aspect (A, B) and the anterior aspect (C, D)

are shown. The opening for the perforating branch at the

lower end of the interosseous membrane was indicated by

the arrowheads. Pp = popliteal artery, At = anterior tibial

artery, Pt=posterior tibial artery, Fb= fibular artery, Pb=

perforating branch of the fibular artery, Cb=communicating

branch of the fibular artery, Al = anterior lateral malleolar

artery, Dp=dorsalis pedis artery.

PpPpAtAt

PtPt FbFb

PbPb

CbCb

AA BB

CbCb

PbPb

FbFbPtPt

AtAtPpPpAtAt

PbPb

AlAl DpDp

CC

AtAt

PbPb

DpDpAlAl

DD

perforating branch of fibular artery penetrated it.

The number of communication branches was one in

seven cases (Figure-2A, C, E, J, K, M, P) and

multiple in the other 11 cases (Figure-2B, D, F, G, H,

I, L, N, O, Q, R), with a maximum of 4 from the

posterior tibial artery and 6 from the fibular artery

(Figure-2H).

The single and multiple communicating branches

manifested differences in their level of distribution.

The single communicating branch was always

found in a dominant region around the level of the

lower end of interosseous membrane of leg,

whereas the multiple communicating branches

were distributed in a wider range between the

middle of the leg and the calcaneus. In the cases of

multiple communicating branches, the highest one

(in 3 cases the highest two; Figure-2I, L, O) was

largest and the other communicating branches

were significantly thinner (Figure-2B, D, F, G, H, N,

Q, R). The level of the highest communicating

branch was higher than the dominant region in 3

cases (Figure-2I, L, O), and in the dominant region

in 8 cases (Figure-2B, D, F, G, H, N, Q, R). The

lowest communicating branch was observed in the

Machida, et al: Diversity of arteries in the leg and foot

296

Figure-2 Schematic drawings of the arterial branches in the lower half of the legThe 18 cases were divided into the fibular artery dominant (10 cases; A-J) and the posterior tibial artery dominant (8 cases; K-R). The

communicating branch was either single in 7 cases (A, C, E, J, K, M, P) or multiple in 11 cases (B, D, F, G, H, I, L, N, O, Q, R). In the cases of

multiple communicating branches, the highest one (in 3 cases the highest two) was largest and the other communicating branches were

significantly thinner. The level of highest communicating branch was higher than the dominant region in 3 cases (I, L, O), in the dominant

region in 8 cases (B, D, F, G, H, N, Q, R). The lowest communicating branch was found in the dominant region in 3 cases (I, O, R) and at the

level of calcaneus in 8 cases (B, D, F, G, H, L, N, Q). The single communicating branch was inclined in 3 cases (A, C, K) and horizontal in 4

cases (E, J, M, P), whereas among the multiple communicating branches the highest one (or two) was obviously inclined.

A B C D E F

G H I J K L

M N O P Q R

dominant region in 3 cases (Figure-2I, O, R) and at

the level of calcaneus in 8 cases (Figure-2B, D, F-H,

L, N, Q).

The single and multiple communicating branches

also manifested differences in inclination. The single

communicating branch was inclined in 3 cases

(Figure-2A, C, K) and horizontal in 4 cases (Fig-

ure-2E, J, M, P), whereas among the multiple

communicating branches the highest one (or two)

was obviously inclined (Figure-2B, D, F, G, H, I, L,

N, O, Q, R). The inclined communicating branch

was connected at the proximal end to the thicker

one and at the distal end to the thinner one of the

two parallel arteries in the posterior compartment

of leg in most cases (10 cases out of 11; Figure-2D,

F-I, L, N, O, Q, R), an arrangement which would

facilitate even circulation on both sides of the ankle

region. The inclination was in the opposite direction

in the other case in which the thicker fibular artery

continued to a very thick perforating branch, and

the tributaries to the posterior tarsal region were

very thin. In this case the communicating branch

may facilitate even circulation in the posterior tarsal

region (Figure-2B).


297

Figure-3 Schematic drawings of the arterial branches in the anterior leg and dorsum of footThe perforating branch of the fibular artery was large in 4 cases (A-D), medium in 6 cases (E-H, K, L) and small in 8 cases (I, J, M, N, O, P,

Q, R). The anterior tibial artery transferred into the dorsalis pedis artery in 14 cases (E-R), the anterior tibial artery and the perforating

branch of almost equal thickness jointed to become the dorsalis pedis artery in 1 case (C), and the perforating branch transferred into the

dorsalis pedis artery in 3 cases (A, B, D). The anterior lateral malleolar artery was single in 10 cases arising either from the anterior tibial

artery (G, K, M, N, P) or from the dorsalis pedis artery (A-E), and multiple in the other 8 cases with higher branches arising at the level up

to the middle of the leg in 7 cases (F, H, I, L, O, Q, R) and without in the other case (J). The number of dorsal roots of dorsal metatarsal

arteries was 4 in 3 cases (B, D, E), 3 in 3 cases (A, G, I), 2 in 4 cases (C, F, H, K), 1 in 2 cases (O, Q) and none in 6 cases (J, L, M, N, P, R).

A B C D E F

G H I J K L

M N O P Q R

2. Arterial branches in the anterior aspect of the

leg

The anterior tibial artery passed through the

proximal part of the interosseous membrane of leg,

descended in the anterior compartment of leg to

send off branches to the extensor muscles of the leg

and around the ankle joint. The perforating branch

of the fibular artery passed through the distal part

of the interosseous membrane to enter the lowest

part of the anterior compartment. Either the

anterior tibial artery or the perforating branch of

the fibular artery became the dorsalis pedis artery

in the dorsum of foot (Figure-1).

3. Perforating branch of the fibular artery

The perforating branch of the fibular artery

pierced the most distal part of the interosseous

membrane in all the cases examined. The perforat-

ing branch was classified into three groups on the

basis of thickness. The large thickness group had

thickness comparable with the two main arteries in

the posterior compartment (4 cases; Figure-3A-

D), the medium thickness group had considerable

thickness, but obviously smaller than these two

arteries, (6 cases; Figure-3E-H, K, L), and the

small thickness group included smallest ones which

were barely detectable (8 cases; Figure-3I, J,

M-R). The thickness of perforating artery was

correlated with the relative thickness of the fibular

and posterior tibial arteries. The large thickness

perforating branch was found in the FAD group,

and the small thickness perforating branch was

mainly found in the PTAD group (Table-1).

4. Dorsalis pedis artery

In 14 cases among the 18 cases examined, the

anterior tibial artery transferred into the dorsalis

pedis artery either without participation of the

perforating branch or with participation of a small

twig of the perforating branch (Figure-4A). In one

case among the 18 examined, the anterior tibial

artery and the perforating branch of almost equal

thickness anastomosed to become the dorsalis pedis

artery (Figure-4B). In the other 3 cases, the per-

forating branch transferred into the dorsalis pedis

artery with participation of a small twig of the

anterior tibial artery (Figure-4C). In the 4 cases of

the large thickness group, the perforating branch

substantially contributed to the dorsalis pedis

artery (Figure-3A-D), whereas in the 6 and 8

cases of the middle (Figure-3E-H, K, L) and small

thickness group (Figure-3I, J, M-R), the anterior

tibial artery transferred into the dorsalis pedis

artery without substantial participation of the

perforating branch.

5. Anterior lateral malleolar artery

The anterior lateral malleolar artery entering the

lateral malleolar network arose either from the


298

AtAt

PbPb

DpDpAA BB CC

AtAt

PbPb

DpDp

（14/18）（14/18）（1/18）（1/18）（3/18）（3/18）

AtAt

PbPb

DpDp

Figure-4 Schematic drawings of the origin of dorsalis pedis artery. At=anterior tibial artery, Pb=perforating branch of thefibular artery, Dp=dorsalis pedis artery

A. The dorsalis pedis artery was formed as continuation of the anterior tibial artery without substantial participation of the perforating

branch (14/18).

B. The dorsalis pedis artery was formed by union of the anterior tibial artery and perforating branch with almost equal thickness (1/18).

C. The dorsalis pedis artery was formed by the perforating branch with participation of a small twing of the anterior tibial artery (3/18).

Size of the perforating branch FAD group PTAD group

The large sized group 4

The middle sized group 4 2

The small sized group 2 6

Table-1 Classification of the perforating branch

anterior tibial artery or from the perforating branch

or from the dorsalis pedis artery in a wide range of

the lower leg and dorsum of pedis. The number of

anterior lateral malleolar arteries was also variable,

being single in 10 cases (Figure-3A-E, G, K, M, N,

P) and multiple in 8 cases (Figure-3F, H-J, L, O, Q,

R). The single anterior lateral malleolar artery

arose at the level of talocrural joint in 5 cases

(Figure-3G, K, M, N, P; Figure-5A) and in the

dorsum of pedis in 5 cases (Figure-3A-E; Fig-

ure-5B). In the cases with multiple anterior lateral

malleolar arteries, the thickest branch of the artery

was found at the level of talocrural joint, and the

other thinner branches were found either from the

anterior tibial artery in the region up to the middle

of the leg in 7 cases (Figure-3F, H, I, L, O, Q, R;

Figure-5C) or as continuation of perforating

branch in the other one case (Figure-3J; Figure-

5D).

6. Arterial distribution in the dorsum of foot

In the dorsum of foot, the dorsal metatarsal

arteries in number were formed both by the

metatarsal branches from the dorsalis pedis artery

or from the arcuate artery and by the perforating

branches from the deep plantar arch, a tributary of

the posterior tibial artery. The number of metatar-

sal branches contributing to the dorsal metatarsal

arteries was variable: 4 branches in 3 cases (Fig-

ure-3B, D, E), 3 branches in 3 cases (Figure-3A, G,

I), 2 branches in 4 cases (Figure-3C, F, H, K), 1

branch in 2 cases (Figure-3O, Q) and no branch in

6 cases (Figure-3J, L-N, P, R). We found a

correlation between the thickness of perforating

branch and the number of metatarsal branches. In

the large thickness group (Figure-3A-D) the num-

ber of metatarsal branches was 3.3 in average, in

the middle thickness group (Figure-3E-H, K, L) it

was 2.2 in average, and in the small thickness

group (Figure-3I, J, M-R) it was 0.6 in average.

The number of metatarsal branches was also

correlated with the relative thickness of the fibular

and posterior tibial artery, and 2.7±1.3 (average

±SD) in the FAD group, and 0.5±0.8 (average

±SD) in the PTAD group (Figure-3). The differ-

ence was significant by Mann-Whitney U test (P

value<0.05).

Discussion

In the present study on the peripheral arterial

branches of the three arteries arising from the

popliteal artery, we obtained novel findings in the

four regions of the leg and foot: 1) communicating

branches between the fibular and posterior tibial

artery; 2) the dorsalis pedis artery formed by the

anterior tibial artery and/or the perforating branch

of the fibular artery; 3) the anterior lateral maleolar

artery distributing to the lateral ankle region; and

4) dorsal metatarsal artery distributing to the

dorsal surface of the second to fifth toes. The three

arteries arising in the popliteal region were the

object of investigation by means of cadaver

dissection and medical imaging, and their branching

patterns in the popliteal fossa 8), and their frequency

of defect 10) were reported. On the peripheral

branches of the three arteries, Adachi 3), Lanz and


299

AA BB

CC DD

AtAt

DpDp（5/18）（5/18）

AtAt

DpDp（5/18）（5/18）

AtAt

DpDp（7/18）（7/18）

AtAt

DpDp（1/18）（1/18）

PbPb

Figure-5 Schematic drawings of the origin of the anteriorlateral malleolar artery entering the lateralmalleolar network

A. The single anterior lateral malleolar artery arose from the

anterior tibial artery at the level of talocrural joint (5/18).

B. The single anterior lateral malleolar artery arose from the

anterior tibial artery in the dorsum of pedis (5/18).

C. The multiple anterior lateral malleolar arteries with a thinner

branch arising from the anterior tibial artery in the region up

to the middle of the leg (7/18).

D. The multiple anterior lateral malleolar arteries with a thinner

branch arising from the perforating branch (1/18).

At= anterior tibial artery, Pb=perforating branch of the fibular

artery, Dp=dorsalis pedis artery,

Wachsmuth 11) and Huber 12) provided some contri-

butions after cadaver dissection.

1. Communicating branch between the fibular and

posterior tibial artery

In the present study, we reported the number,

localization, and inclination of the communicating

branch for the first time. The anatomy of communi-

cating branch was so far reported by Adachi 3), who

claimed that the number and courses of the com-

municating arteries were so diverse that systematic

analysis of the communicating branches was

impossible. After the study by Adachi 3), no ana-

tomical studies on the communicating branches

were reported as far as we know.

We found that the number of communicating

branches was either single (7/18, 38.9%) or multi-

ple (11/18, 61.1%). General description of the

communicating branches in the anatomy textbooks

such as Grayʼs Anatomy 13) and Hollinshead 14) state

that the communicating branch is single, as defined

in the Terminologia anatomica 15). The present

study clarified that the communicating branch was

not always single, but frequently multiple in

number.

The localization of communicating branches was

also diverse. General descriptions of the communi-

cating branch 13) 14) state that the communication

branch represented a branch of the fibular artery at

the level of perforating branch at the lower end of

leg. The present study revealed that the dominant

region of the single communicating artery was

found in the lower end of the leg, but multiple

communicating branches were distributed in a

wider region up to the middle of the leg and down to

the calcaneus. In the cases of multiple communicat-

ing branches, either the highest branch was

thickest (8/11) or the highest two branches were

thickest (3/11). Further novel findings concerned

the inclination of the communicating branch. The

single communicating branch was either horizontal

or slightly inclined, whereas the thickest one of the

multiple communicating branches was considerably

inclined. These facts fitted well with the hypothesis

that the multiple communicating branches contrib-

uted to the equalization of the blood supply between

the lateral and medial side of the leg more

effectively than the single communicating branch.

2. Formation of the dorsalis pedis artery

The dorsalis pedis artery is usually considered to

be a continuation of the anterior tibial artery, and is

formed exceptionally by the perforating branch

from the fibular artery 1) 13) 14). The present study

revealed that the dorsalis pedis artery was formed

by the perforating branch totally in 3 cases (Fig-

ure-3A, B, D) and partially in one case (Figure-3C)

out of 18 cases. The frequency of formation by the

communicating branch (totally 3/18; 16.7%, parti-

ally 1/18; 5.6%) was much higher than that

reported in previous studies such as Huber 12)

(totally 5.0%, partially 0.5%) and Adachi 3)(totally

7.1% and partially 0%).

It is noteworthy that the 4 cases (Figure-3A-D)

with formation of dorsalis pedis artery by the

perforating branch have thick perforating

branches, and belong to the FAD group with

relatively thick fibular arteries. This fact suggests

that the relative thickness of the three major

arteries from the popliteal artery determines in part

the branching and course of the peripheral arteries

in the leg and foot.

3. Anterior lateral malleolar artery

Descriptions of the anterior lateral malleolar

artery in the textbooks and studies up to now were

diverse and sometimes contradictory. It may arise

either from the anterior tibial artery 13) or from the

dorsalis pedis artery 14). Adachi 3) reported that it

arose either from the superior to the talocrural joint

(higher origin) in 4 cases, at the level of the joint

(middle origin) in 16 cases and inferior to the joint

(lower origin) in 32 cases. Lanz 11) reported that it

arose from the level of the talocrural joint or distally

in 90-92%. In these textbooks and studies it was

generally assumed that the anterior lateral malleo-

lar artery was single in number.

The present study revealed for the first time that

the anterior lateral malleolar artery was frequently

multiple in number (8 cases out of 18; Figure-3F,

H-J, L, O, Q, R). In cases of the single artery, it arose

with middle or lower origin, whereas in the cases of

multiple arteries, they arose either with higher or

middle origin, and not with lower origin. The area of

origin of the multiple anterior lateral malleolar

arteries shifted more proximal compared with that

of the single one (Figure-3F, H, I, L, O, Q, R).


300

4. Dorsal metatarsal artery

The dorsalis pedis artery continued to the

arcuate artery traversing the proximal part of the

metatarsal, and during this course the arteries sent

off dorsal roots which joined the ventral roots of

perforating branches from the deep plantar arch to

establish the four metatarsal arteries. The two roots

were not equivalent and either one root or the other

was frequently the dominant one. Adachi 3) classi-

fied the formation of the dorsal metatarsal arteries

into dorsal-dominant, plantar-dominant and equiv-

alent types, and reported the higher incidence of

dorsal roots in the first dorsal metatarsal artery

than the other arteries. According to the data by

Adachi 3), the number of dorsal roots was four in

21.3%, three in 19.6%, two in 10.4%, one in 39.1%

and null in 9.6% of the cases, and the average

number of dorsal roots was 2.04. The number of

dorsal roots found in the present study was a little

lower (1.72) than average, and the cases without

dorsal roots of metatarsal arteries were more

frequent (33.3%).

The present study revealed that the number of

dorsal roots of dorsal metatarsal arteries were

influenced by the thickness of perforating branch

from the fibular artery. The average number of

dorsal roots was 3.3 in the cases with large

perforating branches (Figure-3A-D), 2.2 in the

cases with middle-thickness perforating branches

(Figure-3E-H, K, L), and 0.6 in the cases with

small perforating branches (Figure-3I, J, M-R).

The thickness of perforating branches was influ-

enced by the relative thickness of fibular and

posterior tibial arteries, as stated earlier. Thus one

may expect that the number of dorsal roots was

correlated with the relative thickness of fibular and

posterior tibial artery. In fact, the average number

of dorsal roots was 2.7 in FAD group, and 0.5 in

PTAD group (Figure-6).

References

1) Quain R: The Anatomy of the Arteries of the HumanBody and Its Applications to Pathology and OperativeSurgery. London: Taylor and Walton, 1844.

2) Dubrueil JM: Des Anomalies Artèrielles. Paris: Bail-liere; 1847.

3) Adachi B: Das arteriensystem der Japaner. Bd. 2. Kyoto:Maruzen, 1928.

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5) Sato T, Akita K: Anatomical Variations in Japanese.Tokyo: University of Tokyo Press, 2000.

6) Serita T, Kudoh H, Sakai T: Variability of the arterialdistribution to the rotator cuff muscles and its correla-tion with the diversity of arterial origin. JuntendoMedical Journal, 2014; 60: 137-146.

7) Trotter M: The level of termination of the poplitealartery in the white and the negro. AJPA, 1940; 27:109-118.

8) Kim D, Orron DE, Skillman JJ: Surgical significance ofpopliteal arterial variants: a unified angiographic classi-fication. Ann Surg, 1989; 210: 776-781.

9) Kropman RH, Kiela G, Moll FL, de Vries JP: Variationsin anatomy of the popliteal artery and its side branches.Vasc Endovascular Surg, 2011; 45: 536-540.

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11) Lanz T, Wachsmuth W: Praktische anatomie. Berlin:Springer, 1959.

12) Huber JF: The arterial network supplying the dorsumof the foot. Anat Rec, 1941; 80: 373-391.

13) Williams PL: Grayʼs Anatomy 38th edition. New York:Churchill Livingstone, 1995.

14) Hollinshead WH: Hollinsheadʼ s Textbook of Anatomy.Philadelphia: Lippincott Williams & Wilkins, 1997.

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301

Figure-6 Schematic drawings showing the influence of the relative thickness of the posterior tibial and fibular arteries on thethickness of perforating branch and the number of metatarsal branches

A. fibular artery dominant group

B. posterior tibial artery dominant group

Pt=posterior tibial artery, Fb=fibular artery, Pb=perforating branch of the fibular artery.

2.7±1.3（average±SD）Number of metatarsal branches

0.5±0.8（average±SD）Number of metatarsal branches

FbPt

Pb

FbPt

Pb

A B

Azuki Bean Allergy in a Japanese Child: a Case Report

KIYOTAKA OHTANI＊, MAYU FUJIMOTO＊, HITOMI INAGAKI＊,

KAZUTERU KITSUDA＊, MASAKO KITSUNEZAKI＊, SHINYA NAKAMURA＊

＊Department of Pediatrics, Sagamihara Kyodo Hospital, Kanagawa, Japan

Background: Azuki bean is sometimes a nutritional alternative for those with soybean allergy. Although soybean and peanut are

relatively common food allergens, azuki bean allergy has not previously been reported.

Case Report: A 3-year-old male was referred for investigation of suspected azuki bean allergy. He developed urticarial lesions

within 30 min after eating an azuki bean product (manju, a sort of Japanese sweet), with a similar episode reported 1 year prior.

The total serum immunoglobulin E (IgE) level was 677 IU/ml, with elevated specific IgE antibodies (ImmunoCAP) to soybean,

peanut, kidney bean, and pea. Azuki bean specific IgE antibodies are not available, currently. The wheals produced by skin prick

test (SPT) were boiled azuki bean without sugar 5 mm, yohkan (a typical Japanese sweet) 8 mm, sweetened azuki bean paste 7

mm, and soybean 4 mm. Double-blind placebo-controlled food challenge (DBPCFC) with azuki bean without sugar induced

urticaria after 60 min, which resolved after oral antihistamine administration. He did not develop symptoms after ingestion of

control.

Conclusions: This is the first reported case of immediate-type azuki bean allergy, diagnosed by SPT and DBPCFC. Further

study such as immunoblotting is needed to elucidate the specific allergenic antigen.

Key words: azuki bean, food allergy, immunoglobulin E, double-blind placebo-controlled food challenge, skin prick test

Abbreviations

IgE: immunoglobulin E

DBPCFC: double-blind placebo-controlled food chal-

lenge

rGly m: recombinant Glycine max

SPT: skin prick test

Background

The azuki bean (Vigna angularis) is thought to

have originated in East Asia, and has been eaten in

Japan since ancient times. The seed coat of the

azuki bean contains polyphenols, including antioxi-

dants such as anthocyanins, rutin, and catechin 1),

which have been recommended as a natural means

of combating diabetes and obesity 2). The Japanese

Guideline for Food Allergy recommends other

beans as nutritional alternatives for patients with

soybean allergy. However, some patients may also

develop symptoms of allergy after ingestion of other

beans 3). The current case study is the first reported

case of immediate-type azuki bean allergy in a

Japanese child, which was diagnosed by skin prick

test (SPT) and a double-blind placebo-controlled

food challenge (DBPCFC).

Case report

A 3-year-old male was referred to our hospital

for investigation of suspected azuki bean allergy. He

recently developed a few urticarial lesions within 30

min after eating an azuki bean product (manju, a

sort of Japanese sweet), and his parents reported a

similar episode about 1 year prior. And when he

ingested azuki bean, he has been always observed

immediate reactions. The urticaria was not associ-

ated with symptoms indicating viral infection or

other disease. He was otherwise healthy, with no

history of atopic dermatitis, asthma, or allergic

rhinitis. There was no prior history of allergic

reaction to the other ingredients of the azuki bean

product, or to other legumes such as black-eyed

302

Case Reports


Corresponding author: Kiyotaka Ohtani

Department of Pediatrics, Sagamihara Kyodo Hospital

2-8-18 Hashimoto, Midori-ku, Sagamihara-City, Kanagawa 252-5188, Japan


〔Received Dec. 8, 2014〕〔Accepted Feb. 4, 2015〕

pea, soybean, peanut, kidney bean, or pea.

Physical examination showed a healthy child with

normal vital signs. Examination of the head and neck,

chest, abdomen, and skin were normal. Laboratory

examinations showed a white blood cell count of

13,700/μl (normal range: 7,000-11,000/μl)with 3.5%

eosinophils (normal range: 0-8%). Serum total immu-

noglobulin E (IgE) levels were 677 IU/ml (normal: <

170). Specific IgE (kUA/l)(ImmunoCAP; Phadia AB,

Uppsala, Sweden) showed elevated levels of specific

IgE antibodies to soybean (42.4), peanut (9.03),

kidney bean (70.9), pea (21.9), recombinant Glycine

max (rGly m) 5 (19.6), and rGly m 6 (6.74) (normal

range: all <0.35 kUA/l; Table-1). Azuki bean specific

IgE antibodies are not available, currently.

SPT was performed using commercially available

allergens for soybean, peanut, and wheat (Torii

Pharmaceutical Co., Ltd., Tokyo, Japan), as well as

boiled azuki bean without sugar, yohkan (a typical

Japanese sweet) and sweetened azuki bean paste

(azuki beans and sugar). The wheal for boiled azuki

bean without sugar was 5 mm, yohkan 8 mm,

sweetened azuki bean paste 7 mm, black-eyed pea

paste without sugar 4 mm, soybean 4 mm, peanut 5

mm, and positive control 8 mm (Table-2). A wheal

half diameter larger than that of the positive control

was considered to indicate a positive test 4). The

boiled azuki bean and azuki bean paste that were

utilized in the SPT were azuki bean products of

similar cooking method that has been ingested in

DBPCFC.

After obtaining written informed consent from

the parents, a DBPCFC was performed with azuki

bean paste without sugar and black-eyed pea paste

without sugar as a control. In view of the possibility

of Maillard reaction, DBPCFC was performed using

beans without sugar 5). At 60 min from the start of

the DBPCFC, he had facial flushing and urticaria

over his left axilla and flank. This was considered to

indicate a positive reaction, and oral epinastine

hydrochloride was administered. In contrast, he did

not develop symptoms after ingestion of the control,

and the patient was diagnosed with immedi-

ate-type azuki bean allergy based on the DBPCFC.

No further symptoms were observed after elimina-

tion of azuki beans from his diet.

Discussion

To our knowledge, this is the first reported case

of azuki bean allergy. The azuki bean belongs to the

Fabaceae (legume) family, which also includes the

soybean, black-eyed pea, kidney bean, pea, and

peanut. Patients with allergy to one food in this

family may also have cross-reactivity to other foods

in the same family. In our patient, SPT and specific

IgE showed elevated reactivity to soybean, pea,

peanut, and kidney bean. However, he was able to

eat soybeans, black-eyed peas, peas, kidney beans,

and peanuts without clinical signs of allergy. As

azuki bean specific IgE antibodies are not available,

we performed SPT, which was positive. In addition,

a DBPCFC induced symptoms of allergy.

As the patient had no history of rhinitis or

eczema, he was diagnosed with probable type 1 food

allergy caused by previous intestinal tract sensitiza-

tion 6) 7). A type 2 food allergy associated with hay

fever was considered unlikely because the symp-

toms occurred after ingestion of cooked azuki bean

products. The specific antigen causing this allergy


303

Specific IgE

(kUA/l)

Specific IgE

(kUA/l)

House dust mite 1.49 Soybean 42.4

Cedar 40.5 Peanut 9.03

Japanese alder <0.10 Kidney bean 70.9

Ragweed 0.13 Pea 21.9

Orchard grass <0.10 rGly m 4 <0.10

Wheat 2.43 rGly m 5 19.6

ω-5 gliadin < 0.10 rGly m 6 6.74

Gluten 0.48

Normal range for ImmunoCAP: <0.35 kUA/l.

Table-1 Levels of specific IgE (ImmunoCAP)

Diameter of wheal

(mm)

Diameter of erythema

(mm)

Azuki bean paste without sugar 5 8

Yohkan (a typical Japanese sweet) 8 16

Sweetened azuki bean paste 7 15

Black-eyed pea paste without sugar 4 8

Soybean 4 7

Peanut 5 19

Wheat 2 4

Positive control 8 13

Negative control 2 4

Positive control: histamine dihydrochloride (10 mg/ml), negative

control: 0.9% normal saline.

Table-2 Skin prick test

is unknown, and specific antigen testing for azuki

bean allergy is not currently available. Previous

studies reported that the levels of specific IgE

antibodies to rGly m 5 and rGly m 6 were useful

indicators for the severity of soybean allergy 8) 9).

Although our patient had elevated levels of specific

IgE antibodies to rGly m 5 and rGly m 6, he could

ingest soybeans without clinical signs of allergy.

The azuki bean and soybean might have different

antigens that cause cross-reactivity in these

examinations, and have involved other components.

This case could not be identified the antigen

protein that was included in the azuki bean, also

potentially intolerance for the components con-

tained in the azuki bean could not be negative.

Further study such as immunoblotting is needed to

elucidate the specific allergenic antigen of the azuki

bean.

Conclusions

This case is the first reported case of immedi-

ate-type azuki bean allergy diagnosed by SPT and

DBPCFC in a Japanese child, without clinical

allergy reaction to other foods from the Fabaceae

family. It is important to recognize the possibility of

azuki bean allergy, as azuki bean is sometimes

recommended as a nutritional alternative for

patients with soybean allergy. Further study such

as immunoblotting is needed to elucidate the

specific allergenic antigen of the azuki bean.

Acknowledgments

We appreciate all of our co-workers in Sagami-

hara Kyodo Hospital.

Conflict of interest

The authors have no conflicts of interest to declare.

References

1) Mukai Y, Sato S: Polyphenol-containing azuki bean(Vigna angularis) seed coats attenuate vascular oxida-tive stress and inflammation in spontaneously hyperten-sive rats. J Nutr Biochem, 2011; 22: 16-21.

2) Preuss HG, Bagchi D, Bagchi M: Protective effects of anovel niacin-bound chromium complex and a grape seedproanthocyanidin extract on advancing age and variousaspects of syndrome X. Ann N Y Acad Sci, 2002; 957:250-259.

3) Urisu A, Ebisawa M, Mukoyama T, Morikawa A, KondoN: Japanese guideline for food allergy. Allergol Int, 2011;60: 221-236.

4) Hill DJ, Hosking CS, Reyes-Benito LV: Reducing theneed for food allergen challenges in young children: acomparison of in vitro with in vivo tests. Clin ExpAllergy, 2001; 31: 1031-1035.

5) Maleki SJ, Chung SY, Champagne ET, Raufman JP: Theeffects of roasting on the allergenic properties of peanutproteins. J Allergy Clin Immunol, 2000; 106: 763-768.

6) Ma S: A survey on the management of pollen-foodallergy syndrome in allergy practices. J Allergy ClinImmunol, 2003; 112: 784-788.

7) Valenta R, Kraft D: Type 1 allergic reactions to plant-derived food: a consequence of primary sensitization topollen allergens. J Allergy Clin Immunol, 1996; 97: 893-895.

8) Holzhauser T, Wackermann O, Ballmer-Weber BK, et al:Soybean (Glycine max) allergy in Europe: Gly m 5(beta-conglycinin) and Gly m 6 (glycinin) are potentialdiagnostic markers for severe allergic reactions to soy. JAllergy Clin Immunol, 2009; 123: 452-458.

9) Ito K, Sjolander S, Sato S, et al: IgE to Gly m 5 and Gly m6 is associated with severe allergic reactions to soybeanin Japanese children. J Allergy Clin Immunol, 2011; 128:673-675.

Ohtani, et al: Azuki bean allergy

304

Functional MRI Research on Memory Consolidation and Memory Retrieval Circuit

SEIKI KONISHI＊

＊Department of Neurophysiology, Juntendo University Faculty of Medicine, Tokyo, Japan

It is widely held that the hippocampus plays a crucial role in the retrieval of recent memory, and that memory

representation is later formed in the temporal neocortex through consolidation processes. However, accumulating

evidence from functional magnetic resonance imaging studies has revealed that memory representation is formed

in multiple areas in the lateral temporal cortex (LTC) in humans. Connectivity analyses further suggest possible

memory retrieval circuits in the human temporal lobe: 1) memory is initially encoded into the hippocampus, 2)

the encoded memory is consolidated in the posterior part of the LTC, and 3) the memory stored in the posterior

LTC is retrieved via the anterior part of the LTC.

Key words: memory retrieval, temporal cortex, human, fMRI

Since the initial report of Patient HM, a famous

patient with bilateral medial temporal lobe (MTL)

resection 1), the MTL including the hippocampus

has been a focus of system-level memory research.

His impairments were restricted to recent memory:

He had normal intelligence, and his implicit motor

learning was also normal. However, long-term

memory for recent events was severely impaired.

Importantly, his long-term memory for remote

events was not impaired. Therefore, he had

anterograde and retrograde amnesia, but his

retrograde amnesia was time-limited to recent

events.

The time-limited retrograde amnesia following

damage to the MTL was replicated in lesion studies

using monkeys 2). The performance of the monkeys

was lower than that of control monkeys for memory

that was acquired four weeks before the MTL

lesion, but the performance was similar for memory

that was acquired eight weeks before the MTL

lesion. It is therefore suggested that the MTL was

not necessary eight weeks after the surgery and

that the memory was formed by that time in other

brain areas such as the temporal neocortex.

One direct evidence was provided from electro-

physiological studies using monkeys 3). The mon-

keys were trained to remember several pairs of

pictures, and it was found that the neurons in the

inferior temporal cortex (a part of the LTC)

responded to both of the pictures of a specific pair,

representing the pictures of that pair. The results

indicate that the memory for the paired pictures

was represented in the inferior temporal cortex.

In humans, functional MRI has revealed the

homologue of the memory representation in the

LTC4). The human subjects learned paired items at

two different times: eight weeks before the scan

(remote condition) and immediately before the

scan (recent condition), and remembered the

remote and recent pairs separately during scan-

ning. The brain activity in the anterior part of the

LTC was greater during memory retrieval of the

remote pairs than during memory retrieval of the

recent pairs, indicating memory representation in

the anterior LTC that was formed during the eight

week interval.

Connectivity analyses of fMRI data further

revealed the memory retrieval circuits in the

temporal lobe 5). Three inter-regional interactions

were found (Figure-1). First, the inter-regional

305

Seiki Konishi

Department of Neurophysiology, Juntendo University Faculty of Medicine



〔Received Apr. 27, 2015〕

Lecture Notes


interaction was heightened from the sensory area

to the hippocampus during retrieval of forgotten

remote memory, indicating that initial memory was

encoded from the sensory area to the hippocampus.

Second, the interaction was heightened from the

hippocampus to the posterior part of the LTC

during retrieval of recent memory, indicating the

ongoing consolidation processes for recent memory

from the hippocampus to the posterior LTC. Third,

the interaction was heightened from the posterior

LTC to the anterior LTC during retrieval of remote

memory, indicating that memory is retrieved from

the posterior to the anterior LTC. Although further

studies are required to elucidate memory circuits in

the whole brain, these results illuminate memory

circuits in the temporal lobe that appears to

constitute a core part of the circuits.

References

1) Scoville WB, Milner B: Loss of recent memory afterbilateral hippocampal lesions. J Neurol Neurosurg Psy-chiatry, 1957; 20: 11-21.

2) Zola-Morgan SM, Squire LR: The primate hippocampalformation: evidence for a time-limited role in memorystorage. Science, 1990; 250: 288-290.

3) Sakai K, Miyashita Y: Neural organization for thelong-term memory of paired associates. Nature, 1991;354: 152-155.

4) Yamashita K, Hirose S, Kunimatsu A, et al: Formation oflong-term memory representation in human temporalcortex related to pictorial paired associates. J Neurosci,2009; 29: 10335-10340.

5) Watanabe T, Kimura HM, Hirose S, et al: Functionaldissociation between anterior and posterior temporalcortical regions during retrieval of remote memory. JNeurosci, 2012; 32: 9659-9670.

Konishi: fMRI research on memory circuit

306

Figure-1 Schematic structure of memory circuit in the temporal lobe revealed by connectivity analyses of the brain activityduring retrieval of remote and recent memory

1) from the perception region to the hippocampus during encoding of unfamiliar pairs, 2) from the hippocampus to the posterior temporal

region during memory consolidation, and 3) from the posterior temporal region to the anterior temporal region during retrieval of

consolidated pairs.

Encodingof unfamiliar pairs

Consolidationof memory

Item－specific perception region（FFA/PPA）

Item－specific posterior temporal region

Anterior temporal region

Hippocampus

Retrievalof consolidated pairs

Searching for the Greatest Treasure

JEAN HINO＊

＊Christian Academy in Japan, Tokyo, Japan

307

Jean Hino

Christian Academy in Japan

1-2-14 Shinkawa-cho, Higashi Kurume-shi, Tokyo 203-0013, Japan

E-mail: [email protected]

〔Received Aug. 10, 2015〕

Medical Essays


Many people today love to travel. If you could travel anywhere in the world, where would you

go? What would you want to see? According to one travel website the most popular destination in

2014 was Istanbul, Turkey. Reviews and ratings of hotels, attractions and restaurants are put into

a special algorithm to create the lists of top rated places. Iʼm sure if you want a top rated

experience you can search the web for just the place for you, but I would like to encourage̶

maybe even challenge you̶to rate your experience in a different way.

In the past few years I have had the privilege of traveling with and without my husband to a

variety of places. Weʼve been to Geneva, Hawaii, Nanjing, London, and various places in Japan for

conferences. On our trip to Geneva I extended my time to visit a friend in Heidelberg, Germany.

Iʼve been to Chiang Mai, Hong Kong, and Manila to visit friends and attend conferences. Guam,

Saipan, and various places in Japan, Canada, and the US have been sites weʼve seen with family

and friends. So where is my favorite place? Kansas City, Missouri. If youʼve ever been to Kansas

City, Missouri you may wonder why. Iʼve seen some of the sites and eaten at a few restaurants,

but Iʼve never stayed at a hotel in Kansas City. What make it a treasure for me are the people. Iʼve

stayed with and met people who became like family in a very short time. They made the places we

visited special and fun.

The best place to travel is where you can meet the people and interact with even just a few. Our

latest trip was to Nanjing. I donʼt speak Chinese and I had a day all to myself to explore. I wasnʼt

able to talk to most of the people I met, but I have a

wonderful memory of a family I met on the way to Dr. Sun

Yat-senʼs mausoleum. The dad was trying to take a photo

of his wife and child, and so I offered to take a photo of the

whole family. Afterwards, he wanted to take a photo of me

with his wife and son but the son ran to the dad. So his wife

and I were standing there to take a photo and two other

young ladies jumped into the photo. On the way back down

from the mausoleum I noticed a girl trying to get my photo

so I finally stopped and posed and then motioned for us to

take a photo together. She left with a huge smile.

When I was in Chiang Mai, I stayed with friends for

several days before later staying in a top rated hotel. I

vaguely remember the hotel and have no idea of the food,

but I remember several people. My friends had arranged a

Hino: Searching for the Greatest Treasure

308

taxi to drive me around one day as they were in language school. The taxi driver told me about his

life and country; he even bought me lunch. I did pay him for driving me throughout the day. The

other group of people I may never forget went on the Flight of the Gibbons with me, a zipline

through the rainforest.

Five star hotels and top-of-the-line restaurants are all over the world. Many are large

corporations, so no matter what city or country you are in the facilities are the same. Itʼs great to

stay at a nice hotel and eat delicious food, but I believe the best memories are made from the

people you meet. Take time on your next outing to talk with a local person. Find a way to get to

know at least one person and listen to their story. We all have stories to tell and they are the

greatest treasure of all.

You may wonder how this relates to medicine. For the past two years I have helped with the

Cancer Philosophy Clinics in Higashikurume. I canʼt understand all of the conversations, but I can

see the change in a personʼs face as they share their joys and struggles. Many who come in looking

sad, scared and burdened, leave with a smile or at least with less anxiety on their face. I believe it

is from sharing with others who care enough to listen. Itʼs not always possible to listen to

everyoneʼs story but each of us can listen to at least one other personʼs story and that person can

listen to one more story. We may or may not be able to bring physical healing but a personʼs

physical healing is closely tied to their emotional health. Take time to listen and look at the

personʼs face as you listen; you may be amazed.

309

Department of Neurology

Principal Investigator: Nobutaka Hattori (Professor)

Our department was established in 1968, and Prof.

Hirotaro Narabayashi was appointed as the first

professor of neurology at Juntendo University. Then,

the second professor, Prof. Mizuno, and I, Nobutaka

Hattori, the third professor, were involved in research

on the molecular mechanisms of Parkinsonʼs disease

(PD), starting in 1989. I found a decrease in the

amount of complex I in the substantia nigra of PD

patients 1). More recently, my collaborators and I

identified the disease gene for an autosomal recessive

form of young-onset familial PD, and named it

“parkin”2). This is the second form of familial PD in

which the disease gene has been identified. In

addition, my collaborators and I found that the gene

product, parkin, is directly linked to the ubiquitin-

proteasome pathway as an ubiquitin ligase 3). This

discovery suggested that the protein degradation

system is involved in the pathogenesis of not only the

monogenic form of PD but also sporadic PD.

We are currently working hard on the investigation

and development of therapeutic methods not only for

PD, but also other neurological diseases. I would like

to introduce our department as follows.

Publications:

1) Hattori N, Tanaka M, Ozawa T, Mizuno Y: Immuno-histochemical studies on complexes I, II, III, and IV ofmitochondria in Parkinsonʼs disease. Ann Neurol, 1991;30: 563-571.

2) Hattori N, Kitada T, Matsumine H, Asakawa S, Yama-mura Y, Yoshino H, Kobayashi T, Yokochi M, Wang M,Yoritaka A, Kondo T, Kuzuhara S, Nakamura S, ShimizuN, Mizuno Y: Molecular genetic analysis of a novelParkin gene in Japanese families with autosomalrecessive juvenile parkinsonism: evidence for variablehomozygous deletions in the Parkin gene in affectedindividuals. Ann Neurol, 1998; 44: 935-941.

3) Shimura H, Hattori N, Kubo Si, Mizuno Y, Asakawa S,Minoshima S, Shimizu N, Iwai K, Chiba T, Tanaka K,Suzuki T: Familial Parkinson disease gene product,parkin, is a ubiquitin-protein ligase. Nat Genet, 2000; 25:302-305.

Group Leaders and Research Topics

1. Yasushi Shimo (Associate Professor)

Deep brain stimulation (DBS) has been widely

performed for various medically refractory move-

ment disorders. For PD, the target of DBS is the

subthalamic nucleus (STN) or globus pallidus inter-

nus (GPi). There is some evidence to demonstrate its

effectiveness on motor function and QOL. Our lab has

also been interested in the pathophysiological mecha-

nisms of basal ganglia disorders. Since 2012, we have

been collaborating with the Department of Research

and Therapeutics for Movement Disorders (described

below) and have investigated the therapeutic mecha-

nisms of DBS using electrophysiological methods.

Publications:

1) Nishikawa N, Shimo Y, Wada M, Hattori N, Kitazawa S:Effects of aging and idiopathic Parkinsonʼs disease ontactile temporal order judgment. PLoS One, 2015; 10:e0118331.

2) Shimo Y, Natori S, Oyama G, Nakajima M, Ishii H, Arai H,Hattori N: Subthalamic deep brain stimulation for aParkinsonʼs disease patient with duplication of SNCA.Neuromodulation, 2014; 17: 102-103.

2. Shigeto Sato (Associate Professor)

Our groups are investigating the molecular patho-

genesis of PD using model mice. The recent discovery

of genes and the associated etiology of familial PD has

shed light on the fundamental role of mitochondrial

dysfunction in PD. The discovery and increasing

knowledge of protein and mitochondrial degradation

associated with PINK1/parkin should enhance our

understanding of the common pathological mecha-

nism of PD 1).

Publications:

1) Sato S, Hattori N: Genetic mutations and mitochondrialtoxins shed new light on the pathogenesis of Parkinsonʼsdisease. Parkinsons Dis, 2011; 979231.

3. Shinji Saiki (Associate Professor)

The purpose of our research is to develop

anti-parkinsonian drugs, especially ones modulating

apoptosis and autophagy, an indispensable protein

degradation system 1)-3). In addition, we aim to deter-

mine the exact molecular mechanisms of mitophagy

using chemical biology techniques 4).

Publications:

1) Saiki S, Sasazawa Y, Imamichi Y, Kawajiri S, Fujimaki T,Tanida I, Kobayashi H, Sato F, Ishikawa K, Sato S, Imoto

JuntendoResearch Profiles


Department of Neurology

310

M, Hattori N: Caffeine induces apoptosis by enhance-ment of autophagy via PI3K/Akt/mTOR/p70S6Kinhibition. Autophagy, 2011; 7: 176-187.

2) Fujimaki T, Saiki S, Tashiro E, Yamada D, Kitagawa M,Hattori N, Imoto M: Identification of licopyranocou-marin and glycyrurol from herbal medicines as neuro-protective compounds for Parkinsonʼs disease. PLoSOne, 2014; 9: e100395.

3) Ishikawa K, Saiki S, Furuya N, Yamada D, Imamichi Y,Li Y, Kawajiri S, Sasaki H, Koike M, Tsuboi Y, Hattori N:p150 glued-associated disorders are caused by activationof intrinsic apoptotic pathway. PLoS One, 2014; 9: e94645.

4) Kawajiri S, Saiki S, Sato S, Sato F, Hatano T, Eguchi H,Hattori N: PINK1 is recruited to mitochondria withparkin and associates with LC3 in mitophagy. FEBSLett, 2010; 584: 1073-1079.

4. Manabu Funayama (Associate Professor)

To elucidate the etiology of PD and related dis-

orders, we are constructing a DNA/RNA bank of PD.

So far, this bank has data on over 3,500 patients with

PD and related disorders, and over 800 controls.

Using these resources, we recently identified

CHCHD2 as a novel causal gene of autosomal domi-

nant PD.

Publications:

1) Funayama M, Ohe K, Amo T, Furuya N, Yamaguchi J,Saiki S, Li Y, Ogaki K, Ando M, Yoshino H, Tomiyama H,Nishioka K, Hasegawa K, Saiki H, Satake W, Mogushi K,Sasaki R, Kokubo Y, Kuzuhara S, Toda T, Mizuno Y,Uchiyama Y, Ohno K, Hattori N: CHCHD2 mutations inautosomal dominant late-onset Parkinsonʼs disease: agenome-wide linkage and sequencing study. LancetNeurol, 2015; 14: 274-282.

5. Ryota Tanaka (Associate Professor)

Stroke is a leading cause of death around the world.

Our lab has investigated the mechanisms of ischemic

neuronal cell death and discovered a strong neuropro-

tective effect of small heat shock protein (HSP27) for

acute ischemic stroke. Other research interests are

regenerative medicine, such as the mobilization of

endogenous neural and oligodendrocyte progenitor

cells and axon re-growth after stroke. We have also

reported a lot of important clinical evidence associ-

ated with stroke, such as diabetes, microbleeds,

visceral fat, and TEE. Now, we are planning to

investigate the association between vascular risk

factors and neurodegenerative disorders.

Publications:

1) Miyamoto N, Tanaka R, Shimura H, Watanabe T, Mori H,Onodera M, Mochizuki H, Hattori N, Urabe T: Phospho-diesterase III inhibition promotes differentiation andsurvival of oligodendrocyte progenitors and enhancesregeneration of ischemic white matter lesions in the

adult mammalian brain. J Cereb Blood Flow Metab,2010; 30: 299-310.

2) Teramoto S, Shimura H, Tanaka R, Shimada Y, Miya-moto N, Arai H, Urabe T, Hattori N: Human-derivedphysiological heat shock protein 27 complex protectsbrain after focal cerebral ischemia in mice. PLoS One,2013; 8: e66001.

6. Kazumasa Yokoyama (Lecturer)

Our lab has attempted to elucidate the patho-

mechanisms of neuroimmunological diseases, espe-

cially multiple sclerosis (MS). We have treated more

than 700 patients with neuro-immunological disor-

ders in our outpatient clinic and performed clinical as

well as basic research. We are very interested in the

new MRI analytical methods in MS, and investigating

neurodegenerative roles by analyzing specimens

from patients. We have been collaborating with the

Neuroradiology Department and Immunological

Department of our university, and the Division of

Molecular Neuroimmunology of Hokkaido Univ. and

the Neurological Dept. of TMDU for breakthrough

therapy.

Publications:

1) Tachibana Y, Obata T, Yoshida M, Hori M, Kamagata K,Suzuki M, Fukunaga I, Kamiya K, Yokoyama K, HattoriN, Inoue T, Aoki S: Analysis of normal-appearing whitematter of multiple sclerosis by tensor-based two-com-partment model of water diffusion. Eur Radiol, 2015; 25:1701-1707.

2) Niino M, Mifune N, Kohriyama T, Mori M, Ohashi T,Kawachi I, Shimizu Y, Fukaura H, Nakashima I, Kusu-noki S, Miyamoto K, Yoshida K, Kanda T, Nomura K,Yamamura T, Yoshii F, Kira J, Nakane S, Yokoyama K,Matsui M, Miyazaki Y, Kikuchi S: Apathy/depression,but not subjective fatigue, is related with cognitivedysfunction in patients with multiple sclerosis. BMCNeurol, 2014; 14: 3.

7. Masashi Takanashi (Associate Professor)

We participate in diagnostic neuropathology and

the construction of a brain bank of neurodegenerative

diseases in cooperation with other institutions. We

have a lot of brain samples of Parkinsonʼs disease and

other movement disorders for pathological diagnosis

and biological research.

8. Kazuaki Kanai (Associate Professor)

Our group is investigating mainly clinical neuro-

muscular diseases. We are interested in the contribu-

tions of abnormal nerve/muscular excitability to the

pathogenesis of neuromuscular diseases, and the

development of physiological disease biomarkers.


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Publications:

1) Kanai K, Sawai S, Sogawa K, Mori M, Misawa S, ShibuyaK, Isose S, Fujimaki Y, Noto Y, Sekiguchi Y, Nasu S,Nakaseko C, Takano S, Yoshitomi H, Miyazaki M,Nomura F, Kuwabara S: Markedly upregulated seruminterleukin-12 as a novel biomarker in POEMS syn-drome. Neurology, 2012; 79: 575-582.

9. YumikoMotoi (Senior Associate Professor; Depart-

ment of Diagnosis, Prevention and Treatment of

Dementia)

Our team has devoted itself to patients with

dementia, especially Alzheimerʼs disease. In basic

neuroscience, we have focused on the molecular

pathogenesis of tau with the aim of establishing a new

tau-based drug. In our outpatient clinic, we have

taken care of hundreds of patients with AD, MCI,

DLB, vascular dementia, and iNPH. We are planning

to perform a preventitive exercise trial for MCI.

Publications:

1) Motoi Y, Shimada K, Ishiguro K, Hattori N: Lithium andautophagy. ACS Chem Neurosci, 2014 Apr 30. [Epubahead of print]

10. Yuzuru Imai (Senior Associate Professor; Depart-

ment of Research for Parkinsonʼs Disease)

Our group focuses on the molecular dissection of

Parkinsonʼs disease-associated proteins, which

include PINK1, Parkin, LRRK2, and Vps35, using

Drosophila genetics, and biochemical and cell biologi-

cal approaches.

Publications:

1) Shiba-Fukushima K, Inoshita T, Hattori N, Imai Y:PINK1-mediated phosphorylation of Parkin boostsParkin activity in Drosophila. PLoS Genet, 2014; 10:e1004391.

2) Shiba-Fukushima K, Arano T, Matsumoto G, Inoshita T,Yoshida S, Ishihama Y, Ryu KY, Nukina N, Hattori N,Imai Y: Phosphorylation of mitochondrial polyubiquitinby PINK1 promotes Parkin mitochondrial tethering.PLoS Genet, 2014; 10: e1004861.

11. Atsushi Umemura (Senior Associate Professor;

Department of Research and Therapeutics for

Movement Disorders)

Our department was established for a multidiscipli-

nary approach to movement disorders. We organize a

“Movement Disorder Unit”with neurologists, neuro-

surgeons, psychiatrists, and rehabilitation doctors.

The main topic of our research is deep brain

stimulation for movement disorders.

Publications:

1) Oyama G, Shimo Y, Umemura A, Nishikawa N, NakajimaA, Jo T, Nakajima M, Ishii H, Arai H, Hattori N:Troubleshooting in hospitalized Parkinsonʼs diseasepatients with a history of deep brain stimulation of thesubthalamic nucleus. Neurol Clin Neurosci, 2014; 2: 188-192.

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Department of Gastroenterology


Juntendo Medical Journal2015. 61 (3), 312-313

Principal Investigator: Sumio Watanabe (Professor)

The Department of Gastroenterology of Juntendo

University was established in 1968. Today, about 100

physicians belong to this department, which is one of

the largest clinical departments at Juntendo Univer-

sity. The target organs of our department may be

thought to be gastrointestinal tract organs (esopha-

gus, stomach, and colon). However, our department is

committed to diagnosing and treating diseases not

only in the esophagus, stomach, and colon, but also in

a variety of organs, such as the small intestine, liver,

gallbladder, pancreas, and peritoneum. About 65,000

outpatients attend our department annually, along

with 100 to 120 inpatients at any time. We undertake

substantial clinical and basic research for our patients

regarding these organs and diseases. Our department

is classified into four main research groups: upper

gastrointestinal tract group, lower gastrointestinal

tract group, liver disease group, and hepato-bili-

ary-pancreatic group. Many physicians belong to

each of these groups and undertake research on

interesting themes. You are welcome to join our team

and study with us.

Group Leaders and Research Areas

1) Mariko Hojo (Associate Professor),

Daisuke Asaoka (Associate Professor),

Kenshi Matsumoto (Associate Professor),

Junko Kato (Associate Professor),

Nobuko Serizawa (Associate Professor)

Upper gastrointestinal tract

We have investigated the pathophysiology of

gastroesophageal reflux disease (GERD), histological

markers for laryngo-pharyngeal reflux disease,

Helicobacter pylori (H. pylori)-related gastric cancer

involving epigenetic changes, and carcinogene-

sis-related SNPs of fundic gland gastric cancer, which

is a gastric cancer without H. pylori infection, as basic

research.

We have investigated the endoscopic and clinicopa-

thological characteristics of fundic gland gastric

cancer, ulcer healing after endoscopic mucosal

dissection, the appropriate use of propofol sedatives

during endoscopic mucosal dissection, the clinicopa-

thological characteristics of gastric cancer after

eradication, the relationship between mucosal dam-

age and anticoagulant drugs, chronological changes in

the rate of H. pylori eradication, and therapeutic

effects of functional dyspepsia and GERD, as clinical

research.

Publications:

1) Nagahara A, Hojo M, et al: A randomized prospectivestudy comparing the efficacy of on-demand therapyversus continuous therapy for 6 months for long-termmaintenance with omeprazole 20 mg in patients withgastroesophageal reflux disease in Japan. Scand JGastroenterol, 2014; 49: 409-417.

2) Ueyama H, Matsumoto K, et al: Gastric adenocarcinomaof the fundic gland type (chief cell predominant type).Endoscopy, 2014; 46: 153-157.

3) Matsumoto K, Nagahara A, et al: Development andclinical usability of a new traction device "medical ring"for endoscopic submucosal dissection of early gastriccancer. Surg Endosc, 2013; 27: 3444-3451.

Chemotherapy

Our group has been working on gastrointestinal

cancer chemotherapy from various perspectives. We

also contribute to some international multi-center

clinical trials as well as domestic clinical trials. Here,

we show our ongoing clinical and basic research.

Clinical research: 1) Clinical trial to evaluate the

safety and efficacy of peptide vaccination for cancer

patients. 2) Management tips for decreasing the

adverse events of molecularly-targeted drugs for

metastatic colorectal cancer. 3) Evaluation of the

QOL in cancer patients undergoing chemotherapy. 4)

Clinical trial for the development of a new effective

chemotherapy regime. Basic research: 1) Galectin-3

regulates gastric cancer cell proliferation through a

signaling pathway. 2) Association of serum DAO

activity and gastrointestinal toxicity in advanced

gastric cancer patients receiving chemotherapy.

Publications:

1) Higashihara Y, Kato J, et al: Phase I clinical trial ofpeptide vaccination with URLC10 and VEGFR1 epitopepeptides in patients with advanced gastric cancer. Int JOncol, 2014; 44: 662-668.

2) Kato J, Nagahara A, et al: Phase I study of paclitaxel,cisplatin and 5-fluorouracil combination chemotherapyfor unresectable/recurrent gastric cancer. Adv Med Sci,2010; 55: 137-142.

3) Kato J, Nagahara A, et al: Evaluation of EORTC QLQ-C30 questionnaire in patients undergoing in-hospitalchemotherapy for gastrointestinal cancer in Japan. JGastroenterol Hepatol, 2008; 23 (Suppl 2) : S268-272.

Juntendo Medical Journal 61 (3), 2015

313

2) Taro Osada (Senior Associate Professor),

Naoto Sakamoto (Associate Professor),

Tomoyoshi Shibuya (Associate Professor)

Lower gastrointestinal tract

Our group has conducted basic and clinical

research on the lower gastrointestinal tract as follows:

[Basic research] 1) β-catenin expression and KRAS

gene alteration in laterally spreading colorectal

tumors. 2) HIF1α, PTCH, EphB2, or DNA-repair

protein expression and BRAF mutation in colorectal

serrated adenoma. 3) KRAS/BRAF mutation and

mucin phenotypes in colorectal submucosal carci-

noma. 4) An association of WNT/β-catenin signal

activation with methylation of genes in the serrated

neoplasia pathway of the colorectum. 5) Mucin

phenotypes in sessile serrated adenoma/polyp with

dysplasia and carcinoma. 6) Micro-RNA expression

in sessile serrated adenoma/polyp with dysplasia and

carcinoma. 7) Methylation of DNA repair genes in

ulcerative colitis-associated colorectal cancer. [Clini-

cal research] 1) Histological distinction between the

granular and nongranular types of laterally spreading

tumors of the colorectum. 2) Traction device-assisted

endoscopic submucosal dissection of large superficial

colorectal tumors. 3) Clinicopathologic characteristics of

sessile serrated adenoma/polyp with dysplasia and

carcinoma.

Publications:

1) Murakami T, Mitomi H, et al: Distinct WNT/β-cateninsignaling activation in the serrated neoplasia pathwayand the adenoma-carcinoma sequence of the colorec-tum. Mod Pathol, 2015; 28: 146-158.

2) Ritsuno H, Sakamoto N, et al: Prospective clinical trial oftraction device-assisted endoscopic submucosal dissec-tion of large superficial colorectal tumors using the S-Oclip. Surg Endosc, 2014; 28: 3143-3149.

3) Osada T, Sakamoto N, et al: Process of wound healing oflarge mucosal defect areas that were sutured by using aloop clip-assisted closure technique after endoscopicsubmucosal dissection of a colorectal tumor. GastrointestEndosc, 2013; 78: 793-798.

Inflammatory bowel diseases and small intestine

Our group is working on inflammatory bowel

disease (IBD). We aim to elucidate the mechanism of

its pathogenesis and pathophysiology and to establish

novel treatment methods. Ongoing projects are as

follows: 1) Effects of lymphocytes on the disease

activity, especially focusing on mucosal-associated

invariant T cells. 2) Functions of intestinal microflora

and its potential for novel treatment. 3) Efficacy and

functional mechanism of cytapheresis in IBD patients.

4) Predictive factors of relapse in ulcerative colitis

patients. 5) Examination of small intestinal lesions

using a capsule and double-balloon endoscopy in

order to clarify their pathogenesis.

Publications:

1) Ishikawa D, Okazawa A, et al: Tregs are dysfunctionalin vivo in a spontaneous murine model of Crohnʼ sdisease. Mucosal Immunol, 2013; 6: 267-275.

2) Shibuya T, Osada T, et al: Jejunal capillary hemangiomatreated by using double-balloon endoscopy (withvideo). Gastrointest Endosc, 2010; 72: 660-661.

3) Osada T, Ohkusa T, et al: Comparison of several activityindices for the evaluation of endoscopic activity in UC:inter- and intraobserver consistency. Inflamm BowelDis, 2010; 16: 192-197.

3) Kenichi Ikejima (Associate professor),

Satoko Suzuki (Associate professor),

Shunhei Yamashina (Associate professor),

Kazuyoshi Kon (Associate professor),

Akira Uchiyama (Associate professor)

Liver disease

Our nationally and internationally recognized liver

investigative group conducts a wide range of basic,

epidemiologic, and clinical research. There are

ongoing programs investigating the treatment of

viral hepatitis, the molecular mechanisms of alcoholic

liver injury, non-alcoholic fatty liver disease, and liver

fibrogenesis. The following are particular liver

diseases. Clinical research: 1) The relationship

between liver diseases and lifestyle-related diseases.

2) The treatment and prognosis of chronic viral

hepatitis. 3) The diagnoses of PBC and AIH. 4) The

usefulness of endoscopic injection sclerotherapy and

endoscopic variceal ligation for esophageal varices.

Basic research: 5) Mitochondrial abnormalities and

cellular autophagy in cancers and lifestyle-related

diseases. 6) The role of lipid metabolism in liver

disease. 7) Pathogenesis and mechanism of the

progression of alcoholic liver disease. 8) The inhibi-

tion of activation of stellate cells and liver fibrogene-

sis. 9) The modulation of intestinal functions through

the immune system and pharmacological nutrition

support by amino acids.

Publications:

1) Fukuo Y, Yamashina S, et al: Abnormality of autophagicfunction and cathepsin expression in the liver frompatients with non-alcoholic fatty liver disease. HepatolRes, 2014; 44: 1026-1036.

2) Hosoya S, Ikejima K, et al: Innate immune responsesinvolving natural killer and natural killer T cells promoteliver regeneration after partial hepatectomy inmice. AmJ Physiol Gastrointest Liver Physiol, 2013; 304: G293-299.

3) Yamagata H, Ikejima K, et al: Altered expression andfunction of hepatic natural killer T cells in obese anddiabetic KK-A (y) mice. Hepatol Res, 2013; 43: 276-288.

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Department of Cellular and Molecular Pharmacology

Principal Investigator: Takashi Sakurai (Professor)

Membrane proteins such as receptors, ion channels,

and transporters are major drug targets. The main

interest of our department is to understand the

physiological and pathophysiological functions of

disease-related membrane proteins, particularly with

respect to downstream signaling, macromolecular

complex formation, intracellular trafficking, and

proteolytic processing. We are conducting disease-

oriented basic research using a variety of imaging

techniques, including high-resolution live cell imag-

ing, total internal reflection fluorescence microscopy,

and Förster resonance energy transfer (FRET)

imaging, as well as biochemical and molecular biology

techniques.


1) Takashi Sakurai (Professor), Taku Kashiyama,

and Nobumasa Takasugi (Assistant Professors)

The accumulation and aggregation of amyloid

β-peptide (Aβ) are central to the pathogenesis of

Alzheimerʼs disease. Aβ is a peptide generated from

the membrane-spanning amyloid precursor protein

(APP) via sequential proteolysis by β- and γ-secre-

tases. To identify novel therapeutic targets for

Alzheimerʼs disease, we analyzed membrane micro-

domains, which act as platforms for Aβ production.

We have identified some candidate proteins in the

APP-containing microdomains from brain tissues and

are investigating the regulatory roles of these

proteins in APP processing and trafficking in neu-

rons.

2) Nagomi Kurebayashi/Kunihiro (Senior Associate

Professor)

We are studying Ca2+ regulation in various tissues

including cardiac and skeletal muscles. We are

particularly interested in the relationship between

abnormal Ca2+ homeostasis and arrhythmias. We use

live cell imaging and other techniques to explore the

mechanisms of arrhythmogenesis at the molecular,

cellular, organ, and whole-body levels.

3) Takashi Murayama (Associate Professor)

We aim to elucidate the pathogenic mechanisms

underlying the disease-associated mutations of type 1

ryanodine receptor in order to discover novel drugs

for malignant hyperthermia and central core diseases.

We are also studying the role of mutations of the

cytoplasmic dynein heavy chain in neurodegenera-

tive diseases.

4) Yuji Kamikubo (Assistant Professor)

Various G-protein-coupled receptors (GPCRs)

have been found to localize at the synaptic membrane.

Some of these GPCRs form heteromeric complexes on

the cell surface and cooperatively initiate special

signaling events that each GPCR alone cannot initiate.

We are investigating the complex formation and

functional modulation of GPCRs in the central

nervous system.

Publications

1) Kurosawa M, Matsumoto G, Kino Y, Okuno M, Kuro-sawa-Yamada M, Washizu C, Taniguchi H, Nakaso K,Yanagawa T, Warabi E, Shimogori T, Sakurai T, HattoriN, Nukina N: Depletion of p62 reduces nuclear inclu-sions and paradoxically ameliorates disease phenotypesin Huntingtonʼs model mice. Hum Mol Genet, 2015; 24:1092-1105.

2) Odagiri F, Inoue H, Sugihara M, Suzuki T, Murayama T,Shioya T, Konishi M, Nakazato Y, Daida H, Sakurai T,Morimoto S, Kurebayashi N: Effects of candesartan onelectrical remodeling in the hearts of inherited dilatedcardiomyopathy model mice. PLoS One, 2014; 9:e101838.

3) Kamiya K, Yum SW, Kurebayashi N, Muraki M, OgawaK, Karasawa K, Miwa A, Guo X, Gotoh S, Sugitani Y,Yamanaka H, Ito-Kawashima S, Iizuka T, Sakurai T,Noda T, Minowa O, Ikeda K: Assembly of the cochleargap junction macromolecular complex requires con-nexin 26. J Clin Invest, 2014; 124: 1598-1607.

4) Kamikubo Y, Shimomura T, Fujita Y, Tabata T,Kashiyama T, Sakurai T, Fukurotani K, Kano M:Functional cooperation of metabotropic adenosine andglutamate receptors regulates postsynaptic plasticity inthe cerebellum. J Neurosci, 2013; 33: 18661-18671.

5) Kakizawa S, Yamazawa T, Chen Y, Ito A, Murayama T,Oyamada H, Kurebayashi N, Sato O, Watanabe M, MoriN, Oguchi K, Sakurai T, Takeshima H, Saito N, Iino M:Nitric oxide-induced calcium release via ryanodinereceptors regulates neuronal function. EMBO J, 2012;31: 417-428.


Juntendo Medical Journal2015. 61(3), 314

315

Department of Respiratory Medicine



Principal Investigator: Kazuhisa Takahashi (Profes-

sor)

The Department of Respiratory Medicine atJuntendo University Graduate School of Medicine iscarrying out research on pulmonary disease. Oureight groups are shown below. The research in ourdepartment encompasses a wide range of topics onpulmonary diseases as follows:


1) Kazuhisa Takahashi (Professor) and FumiyukiTakahashi (Associate Professor) : Cancer andpulmonary fibrosis

Our goal in basic research is to understand thebiology of non-small cell lung cancer (NSCLC),thymic cancer, and mesothelioma by using cellculture and animal models, and to validate thesefindings in clinical specimens. Current projectsinclude cancer stem cells (CSCs) and epithelial-mes-enchymal transition (EMT) in the resistance tocancer therapeutics such as gefitinib in NSCLC withactivating EGFR mutation. We have established aunique model to obtain gefitinib-resistant persisters(GRPs) of EGFR-mutant NSCLC that have stem celland mesenchymal features in vitro as well as in vivo.Furthermore, we have integrated these findings withclinical data of NSCLC patients who suffered fromrelapse after initial response to gefitinib. We also havea longstanding interest in the role of CD44 in cancermetastases, and collaborated with Dr. Sayaʼs labora-tory at Keio University to characterize novel func-tions of CD44 variants. To discover the new drug-gable driver oncogene, we are collaborating with thethoracic surgery department and conducting asystematic search for fusion genes by screening 93tyrosine kinases for aberrantly high mRNA expres-sion of the kinase domains in the clinical samples ofNSCLC, SCLC, and thymic cancers.

Recently, it has been reported that EMT of alveolarepithelial cells may be involved in the pathogenesis ofidiopathic pulmonary fibrosis (IPF). However, noagents that can target EMT have been developed forIPF patients. Collaborating with Dr. Sayaʼs laboratoryand Link Genomics, we have established in vitro

models of EMT of alveolar epithelial cells suitable forhigh-throughput screening of antifibrotic agents forIPF. We have screened more than 2,000 drugs andcompounds for anti-EMT activity by employingthese models and selected 11 candidates. We havealso tested these medicines for an antifibrotic effect ina murine pulmonary fibrosis model induced bybleomycin injection in vivo. We are currentlyplanning to conduct a clinical trial of these medicinesfor IPF patients.

Publication:1) Murakami A, Takahashi F, Nurwidya F, Kobayashi I,

Shimada N, Takahashi K, et al: Hypoxia increasesgefitinib-resistant lung cancer stem cells through theactivation of insulin-like growth factor 1 receptor. PLoSOne, 2014; 9: e86459.

2) Yae T, Takahashi K, Saya H, Nagano O, et al: Alterna-tive splicing of CD44 mRNA by ESRP1 enhances lungcolonization of metastatic cancer cell. Nature Commun,2012; 3: 883.

2) Kuniaki Seyama (Senior Associate Professor) :LAM and BHD

One of the missions of a medical university and itsaffiliated hospital should be to contribute to researchon rare diseases whose pathogenesis, pathophysiol-ogy, and therefore established treatment remainunclear. Although many rare and intractable diseasesare recognized in the field of respiratory medicine, wefocus on lymphangioleiomyomatosis (LAM) and Birt-Hogg-Dubé syndrome (BHDS), both characterizedby multiple lung cysts and a propensity for pneumo-thorax. Interestingly, both are tumor suppressor genesyndromes and share not only clinical features butalso molecular aspects in their pathogenesis. LAM iscaused by somatic mutation of the TSC genes,whereas BHDS is caused by germline mutation of theFLCN gene; the proteins encoded by these tumorsuppressor genes are intimately associated within thesame intracellular signaling pathway: the mechanis-tic target of rapamycin (mTOR) pathway. We havebeen intensively engaged in clinical and basicresearch on LAM and BHDS since 1998. Currenttopics in LAM that we are focusing on are a clinicaltrial of sirolimus (mTOR inhibitor) in Japan and theisolation of LAM cells from the lungs. On the otherhand, our current interest in BHDS is to evaluate therole of FLCN in the function and survival of alveolartype II cells.Publication:1) Tobino K, Johkoh T, Fujimoto K, Koike K, Takahashi K,

Seyama K, et al: Computed tomographic features oflymphangioleiomyomatosis: evaluation in 138 patients.Eur J Radiol, 2015; 84: 534-541.

3) Tadashi Sato (Assistant Professor) : COPDChronic obstructive pulmonary disease (COPD) is

one of the leading causes of death worldwide.Cigarette smoking is the most important cause ofCOPD, but the mechanisms of its pathogenesis areincompletely defined, although the disease is knownto be associated with aging. To investigate thepathogenesis of COPD, we established an animalmodel of this disease, senescence marker protein-30

Department of Respiratory Medicine

316

(SMP30) knockout mouse. SMP30 was originallyidentified from rat liver and decreased with aging. Wehave further reported that a specific microRNA,miR-146a, plays a pathogenetic role in the abnormalinflammatory response in COPD using lung fibro-blasts from COPD patients. MicroRNAs are a novelfamily of small noncoding RNAs. To date, nearly1,500 microRNAs have been described in humansand associated with various diseases, includingcancer, heart disease, and lung diseases includingCOPD. Therefore, our research goal is to evaluatewhether microRNAs are associated with the develop-ment and treatment of COPD. We strongly expectthat we can detect microRNAs associated with thedevelopment of COPD through investigation of themicroRNA profile from the lungs of COPD modelmice and believe that microRNAs could be a noveltherapeutic target for COPD.Publication:

1) Koike K, Ishigami A, Sato T, Sekiya M, Takahashi K,Fukuchi Y, Maruyama N, Seyama K, et al: Vitamin Cprevents cigarette smoke-induced pulmonary emphy-sema in mice and provides pulmonary restoration. Am JRespir Cell Mol Biol, 2014; 50: 347-357.

4) Yoshiteru Morio (Associate Professor) and Tetsu-taro Nagaoka (Associate Professor) : Pulmonarycirculation

Our research involves the investigation of vascularreactivity and remodeling pathophysiologically andmolecular-biologically during the development ofpulmonary hypertension. We have elucidated severalmechanisms and contributions of vasomediators topulmonary circulation, including nitric oxide (NO),endothelin, endothelium-derived hyperpolarizing fac-tor, and Rho-kinase. We have also evaluated thepivotal roles of vascular endothelium growth factor(VEGF), angiopoietins, and bone morphogeneticprotein (BMP) in established models of pulmonaryhypertension. Recently, we observed a beneficial andprotective effect of genistein, a soybean-derivedisoflavonoid, against pulmonary hypertension of theestablished models through erythropoietin-mediatedrestoration of endothelial NO synthase function. Ourgroup has established an advanced technique toinvestigate pulmonary vascular response pharmaco-physiologically using catheterization, vascular rings,and isolated perfused lungs. Furthermore, we areplanning to examine pathological changes, includinginflammatory cell infiltration and endothelium-mes-enchymal transition at the pulmonary vasculature,over the time course during the development ofpulmonary hypertension. As mentioned above, ourgroup has performed fruitful research work andprovided useful evidence about the pulmonarycirculation.Publication:

1) Kuriyama S, Morio Y, Toba M, Nagaoka T, Takahashi F,Seyama K, Takahashi K, et al: Genistein attenuateshypoxic pulmonary hypertension via enhanced nitricoxide signaling and erythropoietin system. Am J PhysiolLung Cell Mol Physiol, 2014; 306: L996-L1005.

5) Norihiro Harada (Associate Professor) : Bron-chial asthma

The Asthma Group aims to elucidate the molecularmechanisms underlying asthma and to facilitate thediscovery of new biomarkers and the development ofnew therapeutic targets. Our basic science research isfocused on carrying out state-of-the-art studies ofairway remodeling and the function of alveolarmacrophages and co-stimulatory molecules in asthma.We are also performing some clinical researchincluding biomarker discovery. Recently, we haveindicated an important role for CD27 in the develop-ment of pathogenic Th2 cells in a murine model ofasthma. Therefore, we have aimed at establishing Tcell surface protein CD27 as a new biomarker insubjects with asthma in order to translate our basicresearch in mice into clinical research in humans.Moreover, we are also surveying innate lymphoid cellswith the aim of establishing an asthma biomarker inthe peripheral blood of asthma subjects.

In basic science research, we have particularinterest in the epithelial-mesenchymal transition(EMT) in airway remodeling. Some clinical featuresof asthma have been associated with structuralchanges in the bronchial tissue termed airwayremodeling. Airway remodeling is attributed topersistent airway epithelial damage, inappropriaterepair, and EMT. We recently reported that mechani-cal injury of bronchial epithelial cells induces theproduction of both TGF-β1 and TGF-β2, whichenhances epithelial wound repair. We also reportedthat bronchial epithelial cells produce increasedamounts of IL-13 during inappropriate wound repair.Moreover, our recent projects revealed that the TNFsuperfamily protein TWEAK accelerates the TGF-β-induced features of EMT in bronchial epithelial cells.Taken together, our reports suggest that inappropri-ate bronchial epithelial repair causes a persistentrepair phenotype with overproduction of inflamma-tory mediators and cytokines, including TGF-β,IL-13, and TWEAK, which may contribute to chronicairway changes and remodeling.Publication:

1) Makino F, Ito J, Harada N, Takahashi K, Okumura K,Akiba H, et al: Blockade of CD70-CD27 interactioninhibits induction of allergic lung inflammation in mice.Am J Respir Cell Mol Biol, 2012; 47: 298-305.

6) ShinsakuTogo (Associate Professor) : Fibroblastand CTC

My group aims 1) to elucidate the pathogenesis oflung disease mediated by lung fibroblasts and 2) toevaluate the clinical efficacy of lung cancer bio-markers. Alterations in fibroblast functional capacitycould play a crucial role in the pathogenesis of COPD,bronchial asthma, and pulmonary fibrosis, which arecharacterized by inadequate maintenance of tissuestructures, such as airway and lung parenchymalfibrosis. Fibroblasts are cultured from lung tissueobtained from individuals undergoing surgical opera-tion and are characterized in vitro. We demonstrateda new therapeutic target for inflammatory cytokines


317

to regulate lung fibrotic mechanisms. We alsoinvestigated the role of cancer-associated fibroblasts(CAFs), which promote tumor progression throughspecific communication with cancer cells usingco-injection of CAFs with cancer cells in a mousemodel.

Recently, circulating tumor cells (CTCs) measuredby liquid biopsy have been focused on as a biomarkerrelated to the clinical outcome of cancer patients. Weestablished a highly sensitive detection system,TelomeScan F35, for CTCs in non-small cell lungcancer (NSCLC) patients in collaboration with Onco-lys Biopharma Inc. We have also evaluated therelationship between an immunohistochemical scor-ing system of predictive chemotherapy biomarkersand clinical outcomes in patients with NSCLC. Weconfirmed the improved prospective identification oflung cancer patients who can benefit from treatmentusing biomarkers of chemotherapy response, anddeveloped personalized treatment algorithms.Publication:

1) Nagahama KY, Togo S, Seyama K, Takahashi K,Rennard SI, et al: Oncostatin M modulates fibroblastfunction via signal transducers and activators oftranscription proteins-3. Am J Respir Cell Mol Biol, 2013;49: 582-591.

7) Satomi Shiota (Associate Professor) : SAS andrespiratory care

My group carries out basic research and clinicalresearch on sleep apnea syndrome (SAS) and respi-ratory care. SAS is a major public health problembecause of its high prevalence in morbidity andmortality associated with systemic organ dysfunc-tions, such as cardiovascular disease, diabetes, andstroke. Recently, the association of SAS and cognitivedysfunction has also been widely noted. Regardingbasic research, we have shown that transgenicAlzheimerʼ s disease (AD) mice exhibit significantlyincreased intracellular Aβ in the brain cortex bychronic intermittent hypoxia exposure, which is acharacteristic of SAS. These findings suggested thatSAS would aggravate AD. Regarding clinicalresearch, we have shown that patients with severeSAS developed reversible decreases in regionalcerebral blood flow (rCBF), especially in the frontallobe when awake, while appropriate CPAP treatmentsignificantly improved rCBF in this area. Our nextinterest is to elucidate whether SAS itself causes AD.

As for respiratory care, we are accumulating dailyclinical data on the appropriate use of variousapproaches and types of equipment, such as inva-sive/non-invasive mechanical ventilation and percu-taneous carbon dioxide monitoring for respiratoryfailure. We will soon present the effectiveness andsafe use of non-invasive positive pressure ventilationfor post-liver transplantation patients, focusing ofintrahepatic blood flow.Publication:

1) Shiota S, Takekawa H, Matsumoto S, Takeda K,Nurwidya F, Yoshioka Y, Takahashi F, Hattori N, TabiraT, Motizuki H, Takahashi K: Chronic intermittenthypoxia/reoxygenation facilitate amyloid-β generationin mice. J Alzheimers Dis, 2013; 37: 325-333.

8) Mitsuaki Sekiya (Associate Professor) : Diagnos-tic imaging

Both EBUS-GS (endobronchial ultrasonographywith a guide sheath) for peripheral pulmonary lesionsand EBUS-TBNA (endobronchial ultrasound-guidedtransbronchial needle aspiration) for mediastinallesions are routinely performed in our department.EBUS-GS enables precise and repetitive samplingfrom the same site of peripheral pulmonary lesions.EBUS-TBNA is capable of easily and less invasivelyproviding diagnoses of lymph node metastasis,sarcoidosis, and mediastinal tumors.

Since 1985, ultrasonographic examinations havebeen routinely used for more than 7,000 patients withvarious respiratory diseases, including lung cancer,pleural mesothelioma, pleurisy, mediastinal tumors,and infectious diseases. Both ultrasonically guidedneedle aspiration (USGNA) and biopsy (USGNB)have also been performed. These classical diagnostictechniques are very safe and can be useful even ifpatients have a severe chronic respiratory disease,such as COPD (chronic obstructive pulmonary dis-ease) or IP (interstitial pneumonia). In patients withpulmonary neoplasms and infectious diseases, thediagnostic accuracy rates are 83% and 77%, respec-tively.Publication:

1) Sekiya M, Yoshimi K, Muraki K, Iwakami S, Togo S,Tamaki S, Dambara T, Takahashi K: Do respiratorycomorbidities limit the diagnostic usefulness of ultra-sound-guided needle aspiration for subpleural lesions ?Respir Investig, 2015; 53: 98-103.

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Department of Metabolism and Endocrinology



Figure-1 Role of β cell autophagy in insulin resistance

Insulin Resistance

Fatty Acid↑？？？

autophagic activity↑

Degradation ofunnecessary protein

NormalGlucoseTolerance

Diabetes

reduced β－cell mass compensatory islet hyperplasia

cell deathcell deathproliferation

proliferation

Members

Professor & Chairperson: Hirotaka WatadaSenior Associate Professor: Yoshio FujitaniAssociate Professor: Chie Ohmura, Akio Kanazawa,Tomoaki Shimizu, Takeshi Ogihara, YoshifumiTamura, Fuki Ikeda, Takeshi Miyatsuka,Toyoyoshi Uchida, Tomoya Mita

Assistant Professor: Koji Komiya, Hiromasa Goto,Kageumi Takeno

Research

BackgroundOver seven million Japanese are estimated to have

diabetes mellitus, a serious and costly disease.Diabetes causes several major complications, such asblindness, kidney failure, leg and foot amputations,and cardiovascular diseases. People with diabeteshave a decreased ability to secrete sufficient insulin, ahormone that allows glucose to enter cells and beconverted to energy. If diabetes is not controlled well,excess glucose remains in the blood and damages a lotof organs through vessels throughout the body. Thelong-term goal of our research is to develop bettercare for those with diabetes. To achieve this, we arefocusing on the following projects:

1. The role of autophagy in β-cell homeostasisCommon features of type 2 diabetes mellitus are

progressively decreased pancreatic β-cell functionand β-cell mass, resulting in insufficient insulinsecretion. We have shown that dysfunction of cellularautophagy occurs in islets of diabetic patients as wellas mice under metabolic stress, such as high-fat-fedmice and db/db mice, and that autophagy-deficientmutant mice exhibit impaired glucose tolerance,partly due to the lack of a compensatory increase inβ-cell mass 1). In addition, we have recently found thatthe forced expression of human IAPP, which isthought to cause β-cell failure in diabetic patients,caused deterioration of glucose tolerance in mice witha β-cell-specific autophagy defect, indicating thatincreased autophagy may enhance the toxic potentialof hIAPP in diabetic patients 2). Now, we are exploringfurther molecular mechanisms of how autophagicdysfunction is induced in β cells under conditions ofmetabolic stress, and what role autophagy has inregulating β-cell survival and/or replication.

2. Regulation of glucose profiles by zinc signalsZinc is an essential nutrient for living organisms

because its deficiency causes growth retardation,immunodeficiency, hypogonadism, and neuronal and


319

sensory dysfunctions. Intracellular zinc homeostasis iscontrolled via coordinated regulation of zinc influx andefflux, where zinc transporters have essential roles.Recent genome-wide association studies (GWAS) havedemonstrated that common variants of SLC30A8increase susceptibility to type 2 diabetes. SLC30A8encodes zinc transporter-8 (ZnT8), which delivers zincfrom the cytoplasm into insulin granules. In order touncover the roles of ZnT8 and its pathologicalimplications, we have generated β-cell-specific Slc30a8-deficient mice. We demonstrated that zinc co-secretedwith insulin suppressed hepatic insulin clearance3). Ourstudy highlighted a novel role of zinc-mediated intra-organ communication, referred to as“zinc flow”,between the pancreas and the liver.We are currently investigating further molecular

factors underlying the role of zinc in pathologicalconditions of lifestyle-related diseases.

3. Understanding the progression of atherosclerosisin diabetic patientsPatients with type 2 diabetes mellitus are at high

risk of developing cardiovascular diseases. However,it largely remains unknown which risk factors indiabetic conditions contribute to the progression ofatherosclerosis because diabetic patients have manyrisk factors, such as hyperglycemia accompanied byinsulin resistance, hyperinsulinemia, hypertension,and hyperlipidemia.In order to quantify the adhesion of monocytes to

the endothelium, which is one of the earliest events innaturally occurring experimental animal models ofatherosclerosis in vivo, we have established a new enface method for optimal observation of endothelialsurface (NEMOes) 4). This method allows us toobserve the entire surface of the endothelium with aclear focused image, and thus to quantify the numberof monocytes adhering to every region of rodentthoracic aorta. Using this NEMOes method, we areuncovering how each risk factor contributes to theprogression of atherosclerosis, which would lead tonew therapeutic approaches for preventing andcuring cardiovascular diseases in patients with type 2diabetes.

4. Investigating mechanisms of insulin resistance inmuscle and liverIn most Asian countries, type 2 diabetes can easily

develop in subjects with normal body mass index(BMI) (<25 kg/m2), in contrast to the case inEuropean countries and the USA, although the

mechanisms that induce metabolic disorders innormal-weight subjects are not fully understood.It has been shown that ectopic fat accumulation in

muscle and liver induces insulin resistance in theseorgans, independent of obesity. We have measuredintramyocellular lipid (IMCL) and intrahepatic lipid(IHL), using proton magnetic resonance spectro-scopy (1H-MRS), in order to investigate the role ofectopic fat accumulation in insulin resistance, andfound that a short period of calorie restriction andexercise therapy decreased IHL and IMCL, respec-tively 5), suggesting that dietary and exercise inter-vention in metabolic diseases may directly decreaseectopic fat and improve metabolic states in liver andmuscle, independent of body weight reduction.On the basis of these findings, we hypothesized that

diet and physical activity directly regulate intracellu-lar lipid accumulation and insulin sensitivity in muscleand liver independently of obesity. To test thishypothesis, we have recently evaluated tissue-spe-cific insulin resistance in muscle and liver of non-obese diabetic patients by using a euglycemichyperinsulinemic clamp with a glucose tracer, search-ing for determinants of insulin resistance, such asectopic fat and lifestyle factors. We also generated amouse model of physical inactivity and investigatedhow physical inactivity regulates IMCL and insulinsensitivity in muscle. This approach will help us tounderstand the pathophysiology of metabolic disor-ders in non-obese diabetic subjects and bring newinsight for treatment beyond the idea of body weightreduction.

References

1) Ebato C, et al: Autophagy is important in islet homeosta-sis and compensatory increase of beta cell mass inresponse to high-fat diet. Cell Metab, 2008; 8: 325-332.

2) Shigihara N, et al: Human IAPP-induced pancreatic β

cell toxicity and its regulation by autophagy. J ClinInvest, 2014; 124: 3634-3644.

3) Tamaki M, et al: The diabetes-susceptible geneSLC30A8/ZnT8 regulates hepatic insulin clearance. JClin Invest, 2013; 123: 4513-4524.

4) Ervinna N, et al: Anagliptin, a DPP-4 inhibitor, sup-presses proliferation of vascular smooth muscles andmonocyte inflammatory reaction and attenuates athero-sclerosis in male apo E-deficient mice. Endocrinology,2013; 154: 1260-1270.

5) Tamura Y, et al: Effects of diet and exercise on muscleand liver intracellular lipid contents and insulin sensitiv-ity in type 2 diabetic patients. J Clin Endocrinol Metab,2005; 90: 3191-3196.

Leaders: Professor Yasuhiko Tomino

SeniorAssociateProfessorSatoshiHorikoshi

Chronic kidney disease (CKD) is a worldwide

public health problem. In Japan by the end of 2013,

more than 300,000 patients have had maintenance

dialysis therapy (JSDT). In Japan, the major causes

of end-stage kidney disease (ESKD) are chronic

glomerulonephritis, especially IgA nephropathy,

type 2 diabetic nephropathy and hypertensive

nephrosclerosis. Since the pathogenesis of IgA

nephropathy is still obscure, no specific treatment is

currently available. However, efforts by our investi-

gators have gradually clarified various aspects of

the pathogenesis and treatment of IgA nephrop-

athy. Type 2 diabetic nephropathy is one of the

major long-term microvascular complications oc-

curring in nearly 40% of diabetic patients in Japan.

The pathogenesis of diabetic nephropathy includes

both genetic and environmental factors. The

objective of this session is to summarize our

research activities in the fields of nephrology/hy-

pertension, including renal replacement therapies

(RRT), namely, peritoneal dialysis (PD) and hemo-

dialysis (HD).

Details of the basic research groups

1. IgA nephropathy

Leaders: Yusuke Suzuki (Associate Professor)

Hitoshi Suzuki (Associate Professor)

Our studies have shown that 1) IgA1 with

aberrant galactosylation increases in the blood and

urine, 2) IgA1 with aberrant galactosylation is de-

posited in the glomerular mesangial areas, 3) bone

marrow cells (BMCs) may also be involved in the

increase in IgA1 with aberrant galactosylation

observed in the blood, 4) the cells responsible for

production are B cells that come into contact with

antigens in the mucosa, and 5) the tonsils are

important as one of the sites of responsible lesions.

Therefore, clarification of the mechanism of aber-

rantly galactosylated IgA1 production occurring

due to abnormal mucosal immunity shows a high

possibility of leading to clarification of the mecha-

nism of onset of IgA nephropathy and the develop-

ment of treatment methods. The results of future

research are eagerly awaited.

2. Diabetic nephropathy

Leader: Tomohito Gohda (Associate Professor)

Diabetic nephropathy is the leading cause of

ESKD worldwide. Many factors, such as genetic

and non-genetic promoters, hyperglycemia, the

accumulation of advanced glycation end-products

(AGEs), dyslipidemia, hyperuricemia, a high-pro-

tein diet, obesity, systemic and/or glomerular

hypertension and albuminuria/proteinuria itself,

influence the progression of diabetic nephropathy.

However, current treatments remain suboptimal.

We reported that the pathological changes in the

glomeruli of KK-Ay mice were consistent with

those in the early stage of human type 2 diabetic

nephropathy. The KK-Ay mouse, especially in

terms of histopathological findings, is considered to

be a suitable animal model for type 2 diabetic

nephropathy. Morphometric analysis has contrib-

uted greatly to our understanding of diabetic

nephropathy. The levels of the urinary albu-

min/creatinine ratio (ACR) of KK-Ay mice were

significantly increased. The levels of HbA1c in

KK-Ay mice were also significantly higher than

those in control mice. This spontaneous animal

model is useful to discover novel therapies in

patients with diabetic nephropathy.

3. Complement activity

Leader: Isao Ohsawa (Associate Professor)

Earlier studies indicated that IgA per se activates

the alternative pathway of complements, whereas

more recent data have also shown the activation of

the lectin pathway in patients with IgA nephropathy.

Some investigators reported the contributions of

both mannose-binding lectin (MBL) and L-ficolin to

the progression of IgA nephropathy. We hypothe-

sized that serum levels of complement components

and regulatory proteins in patients with IgA nephro-

pathy are correlated with its pathogenesis. We thus

320

Division of Nephrology, Department of Internal Medicine



clarified the variations in serum levels of complement

components and complement regulatory proteins

(CRPs) in patients with IgA nephropathy. It appears

that hypercomplementemia occurs in the progres-

sion of IgA nephropathy and is controlled by an

increase of CRPs. In particular, higher levels of

serum C4 binding protein (C4bp) may indicate the

severity of histological injury in this disease. In

histological study to the specimens of IgA nephro-

pathy, we found the patients who have extra-glo-

merular (Bowmanʼs capsule and/or arteriole) depos-

its present worse clinical outcomes.

4. Podocyte biology

Leader: Teruo Hidaka (Associate Professor)

The development of glomerulosclerosis in several

human and experimental diseases is associated with

podocyte injury. The number of podocytes per

glomerulus might be a podocyte injury parameter

and provide prognostic information in patients with

IgA nephropathy and diabetic nephropathy. Podo-

cyte injury may be caused by apoptosis, necrosis,

detachment from the glomerular basement mem-

brane (GBM) or autophagy of such cells. It is specu-

lated that depositions of immune complexes in the

glomerular capillary walls and/or high glucose, glo-

merular enlargement, some cytokines or ROS

produced by glomerular resident cells might induce

podocyte injury. We reported that podocyte inju-

ries, that is, reduction of the absolute number per

glomerulus and the increase of glomerular surface

area covered by one podocyte, were related to the

progression of the disease in patients with IgA

nephropathy and the spontaneous animal model,

namely, the KK-Ay mouse. Thus, podocyte injury

might provide additional prognostic information in

such diseases.

5. Renal replacement therapy

Leaders: Chieko Hamada (Associate Professor)

Yoshio Shimizu (Associate Professor)

Hiroaki Io (Associate Professor)

Peritoneal dialysis (PD) is an effective treatment

for ESKD patients. A common functional change in

the peritoneal membrane is ultrafiltration failure,

which is related to the duration of PD and structural

alterations of the peritoneal membrane. These

pathological alterations of the peritoneal membrane

in long-term PD patients may progress to encapsu-

lating peritoneal sclerosis (EPS), which is a serious

complication in PD patients. It is well known that

the characteristics of peritoneal findings in long-

term PD patients are severe submesothelial com-

pact (SMC) zone thickening, loss of mesothelial

cells and neoangiogenesis with vasculopathy.

Changes of peritoneal solute transport in long-term

PD patients often result from an increased vascular

surface area with vasculopathy. Angiogenesis and

vasculopathy in the peritoneum may play an

important role in the regulation of water and solute

transportation in the peritoneum. It is necessary to

evaluate the relationship between vascular changes

and the development of peritoneal fibrosis.

It appears that blood pressure, residual glomeru-

lar filtration rate (GFR) and serum albumin levels

are predictive factors for left ventricular mass

index (LVMI) at the initiation of HD. It is important

to treat hypertension before the initiation of HD,

and to treat hypertension, overhydration based on

plasma ANP and anemia after its initiation. These

findings may have some therapeutic implications in

the treatment strategy of pre-dialysis and HD

patients. Now, we are using echocardiography

widely for the evaluation of cardiac structures and

function in PD and HD patients.

Selected readings

1) Suzuki Y, et al: Diagnosis and activity assessment ofimmunoglobulin A nephropathy: current perspectives onnoninvasive testing with aberrantly glycosylated immu-noglobulin A-related biomarkers. Int J Nephrol RenovascDis, 2014; 7: 409-414.

2) Furukawa M, et al: Pathogenesis and novel treatmentfrom the mouse model of type 2 diabetic nephropathy.Scientific World Journal, 2013; 928197.

3) Asanuma K, et al: The role of podocytes in proteinuria.Nephrology (Carlton), 2007: 12 Suppl 3: S15-20.

4) Ohsawa I, et al: Pathological scenario with the man-nose-binding lectin in patients with IgA nephropathy. JBiomed Biotechnol, 2012; 2012: 476739.

5) Tomino Y: Mechanisms and interventions in peritonealfibrosis. Clin Exp Nephrol, 2012; 16: 109-114.


321

1. Perinatal Medicine

Group leader: Atsuo Itakura (Professor of Obstetrics)

Shintaro Makino (Associate Professor)

Research Projects

1) Prediction of Preterm Birth

Preterm birth is one of the major causes of

neonatal death; thus, better diagnostics are neces-

sary for the subsequent intensive care. However, it

is still difficult to predict women who will develop

preterm birth with high positive predictive value.

Consequently, we have been investigating the

possibility of maternal peripheral leukocytes as a

marker to predict women with a risk of preterm

labor using leukocyte migration assay, in collabora-

tion with the University of Alberta, Canada.

2) Fetal Ischemic Brain Injury

Fetal hypoxic ischemic encephalopathy is the

leading cause of cerebral palsy, although the

mechanism of cerebral palsy caused by fetal

ischemia has not been elucidated yet. Collaborating

with a group from the University of Gothenburg,

Sweden, we are attempting to reveal the mecha-

nism of ischemic cerebral palsy.

3) Novel Ultrasonographic Technique

It is important to diagnose the bleeding point on

the uterine wall in patients with postpartum

hemorrhage and to decide how to manage and treat

it. We are developing a novel ultrasonographic

imaging system using contrast media with the

support of Hitachi Ltd. This new technique enables

visualization of uterine bleeding at the bedside,

which may be a more accurate and rapid modality

for identification of the focus of intractable bleeding,

leading to safer management of patients. As above,

to improve maternal and fetal outcome during the

perinatal and peripartum period, international joint

research between industry and universities is

currently being conducted.

Recent publications

1) Okabe H, Makino S, Kato K, Matsuoka K, Seki H, TakedaS: The effect of progesterone on genes involved inpreterm labor. J Reprod Immunol, 2014; 104-105: 80-91.

2) Suzuki T, Tsurusaki Y, NakashimaM,Miyake N, Saitsu H,Takeda S, Matsumoto N: Precise detection of chromo-

somal translocation or inversion breakpoints by whole-genome sequencing. J Hum Genet, 2014; 59: 649-654.

3) Yamamoto E, Takeda S, Watada H: Increased expres-sion of ERp57/GRP58 is protective against pancreaticbeta cell death caused by autophagic failure. BiochemBiophys Res Commun, 2014; 453: 19-24.

4) Yorifuji T, Makino S, Takeda S: Effectiveness of delayedabsorbable monofilament suture in emergency cerclage.Taiwan J Obstet Gynecol, 2014; 53: 382-384.

5) Kinoshita K, Takeda J, Matsuoka K, Takeda S, Eguchi Y,Oda H, Eguchi N, Urade Y: Expression of lipocalin-typeprostaglandin D synthase in preeclampsia patients: anovel marker for preeclampsia. Hypertens Res Preg-nancy, 2014; 2: 72-77.

2. Gynecologic Oncology

Group leader: Satoru Takeda (Professor and Chief)

Yasuhisa Terao (Associate Professor)

Research Projects

1) The metastatic potential acquisition mechanism

of endometrial cancer cells

2) Prediction of endometrial cancer lymph node

metastasis

3) Treatment strategies for uterine sarcoma

4) Novel diagnosis by detection of circulating tumor

cells in ovarian tumor disease

Recent publications

1) Yusuf N, Inagaki T, Kusunoki S, Okabe H, Yamada I,Matsumoto A, Terao Y, Takeda S, Kato K: SPARC wasoverexpressed in human endometrial cancer stem-likecells and promoted migration activity. Gynecol Oncol,2014; 134: 356-363.

2) Maruyama Y, Miyazaki T, Ikeda K, Okumura T, Sato W,Horie-Inoue K, Okamoto K, Takeda S, Inoue S: Shorthairpin RNA library-based functional screening identi-fied ribosomal protein L31 that modulates prostatecancer cell growth via p53 pathway. PLoS One, 2014; 9:e108743.

3) Goto Y, Kametani Y, Kikugawa A, Tsuda B, MiyazawaM, Kajiwara H, Terao Y, Takekoshi S, Nakamura N,Takeda S, Mikami M: Defect of tropomyosin-relatedkinase B isotype expression in ovarian clear cell adeno-carcinoma. Biosci Trends, 2014; 8: 93-100.

4) Gong C, Fujino K, Monteiro LJ, Gomes AR, Drost R,Davidson-Smith H, Takeda S, Khoo US, Jonkers J,Sproul D, Lam EW: FOXA1 repression is associatedwith loss of BRCA1 and increased promoter methylationand chromatin silencing in breast cancer. Oncogene,2014 Dec 22. doi: 10.1038/onc.2014.421.

5) Ujihira T, Ikeda K, Suzuki T, Yamaga R, Sato W, Horie-Inoue K, Shigekawa T, Osaki A, Saeki T, Okamoto K,Takeda S, Inoue S: MicroRNA-574-3p, identified by

322

Department of Obstetrics and Gynecology



microRNA library-based functional screening, modu-lates tamoxifen response in breast cancer. Sci Rep, 2015;5: 7641.

3. Reproductive Medicine

Group Leader: Keiji Kuroda (Associate Professor)

Research Projects

1) Mechanism analysis of embryo implantation

and miscarriage upon decidual transformation

of human endometrial stromal cells

2) Approach to treatment of unexplained recur-

rent implantation failure and miscarriage in

fertility treatment

3) Application of oocyte activation with sperm factor,

phospholipase Cζ (zeta) in fertility treatment

4) Evaluative analysis of effect of subclinical or

overt hypothyroidism on ovarian reserve

5) Assessment of impact of endometriosis on ovarian

function

Recent publications

1) Kuroda K, Uchida T, Nagai S, Ozaki R, Yamaguchi T,Sato Y, Brosens JJ, Takeda S: Elevated serum thy-roid-stimulating hormone is associated with decreasedanti-Müllerian hormone in infertile women of reproduc-tive age. J Assist Reprod Genet, 2015; 32: 243-247.

2) Nakagawa K, Kwak-Kim J, Ota K, Kuroda K, Hisano M,Sugiyama R, Yamaguchi K: Immunosuppression withtacrolimus improved reproductive outcome of womenwith repeated implantation failure and elevated periph-eral blood Th1/Th2 cell ratios. Am J Reprod Immunol,2015; 73: 353-361.

3) Kuroda K, Venkatakrishnan R, Salker MS, Lucas ES,Shaheen F, Kuroda M, Blanks A, Christian M, Quenby S,Brosens JJ: Induction of 11β-hydroxysteroid dehydro-genase type 1 and activation of distinct mineralocorti-coid receptor- and glucocorticoid receptor-dependentgene networks in decidualizing human endometrialstromal cells. Mol Endocrinol, 2013; 27: 192-202.

4) Kuroda K, Venkatakrishnan R, James S, Sucurovic S,Mulac-Jericevic B, Lucas ES, Takeda S, Shmygol A,Brosens JJ, Quenby S: Elevated periimplantation ute-rine natural killer cell density in human endometrium isassociated with impaired corticosteroid signaling indecidualizing stromal cells. J Clin Endocrinol Metab,2013; 98: 4429-4437.

5) Kuroda M, Kuroda K, Arakawa A, Fukumura Y, KitadeM, Kikuchi I, Kumakiri J, Matsuoka S, Brosens IA,Brosens JJ, Takeda S, Yao T: Histological assessment ofimpact of ovarian endometrioma and laparoscopiccystectomy on ovarian reserve. J Obstet Gynaecol Res,2012; 38: 1187-1193.

4. Womenʼs Health & Sports Medicine

Group Leader: Mari Kitade (Associate Professor)

Research Projects

1) Management of themenstrual condition for female

athletes with hormonal therapy to prevent stress

fracture

2) Basic research on the role of steroid hormone

for bone, muscle, and locomotive power with

transgenic mice

3) The role of stromal fibroblasts in endometriosis

promotingmalignant change, invasion, and refrac-

toriness

4) The efficacy of ovarian tissue vitrification as in

patient with primary ovarian insufficiency

Recent publications

1) Aoki Y, Kikuchi I, Kumakiri J, Kitade M, Shinjo A, OzakiR, Kawasaki Y, Takeda S: Long unidirectional barbedsuturing technique with extracorporeal traction inlaparoscopic myomectomy. BMC Surg, 2014; 14: 84.

2) Kumakiri J, Kikuchi I, Sogawa Y, Jinushi M, Aoki Y,Kitade M, Takeda S: Single-incision laparoscopic sur-gery using an articulating monopolar for juvenile cysticadenomyoma. Minim Invasive Ther Allied Technol,2013; 22: 312-315.

3) Kumakiri J, Kikuchi I, Kitade M, Matsuoka S, Kono A,Ozaki R, Takeda S: Association between uterine repairat laparoscopic myomectomy and postoperative adhe-sions. Acta Obstet Gynecol Scand, 2012; 91: 331-337.

4) Jinushi M, Arakawa A, Matsumoto T, Kumakiri J, KitadeM, Kikuchi I, Sakamoto K, Takeda S: Histopathologicanalysis of intestinal endometriosis after laparoscopiclow anterior resection. J Minim Invasive Gynecol, 2011;18: 48-53.

5) Kitade M, Takeuchi H, Jinushi M, Kikuchi I, Kumakiri J,Kuroda K: Testicular feminization with persistent wolf-fian duct and müllerian remnants: similar to Mayer-Rokitansky-Kuster -Hauser syndrome. Fertil Steril, 2009;92: 2034-2036.


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324

Department of Hematology



Principal Investigator: Norio Komatsu (Professor and

Chairman)

The research in our department encompasses awide range of topics on hematological malignancies,including myeloproliferative neoplasms (MPN), leu-kemias, lymphomas, myelodysplastic syndromes(MDS) and multiple myelomas (MM). We aim toclarify the molecular pathogeneses of these diseasesand utilize this information for diagnosis and treat-ment. We have also been performing clinical studiesbased on molecular-targeted therapies and transplan-tation medicine.


1) Norio Komatsu (Professor) andMarito Araki (Asso-ciate Professor)

We focus on studying Philadelphia chromosome-negative MPN. We developed original assay systemsfor the detection of JAK2 and MPL mutations thatare frequently found in MPN patients. Utilizing theseassays, we investigated clinical features associatedwith gene mutations in Japanese MPN patients andfound that“triple-negative”MPN patients are sub-stantially younger than those harboring JAK2, MPL

or CALR mutation. This suggests that“triple-nega-tive”Japanese MPN patients have a genetic back-ground that promotes MPN development, which weare investigating by next-generation sequencing.

JAK2, MPL or CALR mutant proteins found inMPN have been shown to induce constitutiveactivation of cytokine-receptor signaling pathwaysthat include erythropoietin and thrombopoietin.Understanding the molecular mechanisms by whichmutant proteins transform cells is crucial to developbetter diagnosis and treatment for MPN. Since wepreviously established a multi-potent hematopoieticcell line, UT-7, and its sublines that respond tovarious cytokines, we utilize these cell lines to studyJAK2, MPL and CALR mutant protein function interms of cell proliferation and differentiation. Morerecently, we adopted iPS cell technology to advanceour findings in a more relevant in vitro model system.Publications:

1) Shirane S, et al: JAK2, CALR, and MPL mutation spec-trum in Japanese patients with myeloproliferativeneoplasms. Haematologica, 2015; 100: e46-48.

2) Morishita S, et al: Melting curve analysis after T alleleenrichment (MelcaTle) as a highly sensitive and reli-able method for detecting the JAK2V617F mutation.PLoS One, 2015; 10: e0122003.

3) Shirane S, et al: Consequences of the JAK2V617F alleleburden for the prediction of transformation intomyelofibrosis from polycythemia vera and essentialthrombocythemia. Int J Hematol, 2015; 101: 148-153.

4) Shirane S, et al: Current problems in the diagnosis of

Philadelphia-negative myeloproliferative neoplasms inJapan. Rinsho Ketsueki, 2015; 56: 877-882.

5) Harada-Shirado K, et al: Dysregulation of the MIRLET7/HMGA2 axis with methylation of the CDKN2A promoterin myeloproliferative neoplasms. Br J Haematol, 2015;168: 338-349.

6) Takei H, et al: Detection of MPLW515L/K mutationsand determination of allele frequencies with a single-tube PCR assay. PLoS One, 2014; 9: e104958.

7) Edahiro Y, et al: JAK2V617F mutation status and alleleburden in classical Ph-negative myeloproliferativeneoplasms in Japan. Int J Hematol, 2014; 99: 625-634.

8) Mitsumori T, et al: Hypoxia inhibits JAK2V617F activa-tion via suppression of SHP-2 function in myeloprolifera-tive neoplasm cells. Exp Hematol, 2014; 42: 783-792.

9) Morishita S, et al: Alternately binding probe competitivePCR as a simple, cost-effective, and accurate quantifica-tion method for JAK2V617F allele burden in myeloproli-ferative neoplasms. Leuk Res, 2011; 35: 1632-1636.

Other research projects include understanding themolecular mechanisms of ATRA-induced granulo-cytic differentiation in acute promyeloid leukemiacells, and screening diagnostic markers for lymphomaby cap analysis of gene expression.Publications:

1) Sunami Y, et al: Inhibition of the NAD-dependentprotein deacetylase SIRT2 induces granulocytic differ-entiation in human leukemia cells. PLoS One, 2013; 8:e57633.

2) Akihiko Goto (Senior Associate Professor)Endoplasmic reticulum (ER) is responsible for

protein folding, modification and trafficking. However,some newly synthesized proteins are not foldedproperly. Although the accumulation of unfoldedproteins induces ER stress and triggers the unfoldedprotein response that acts against stress-mediatedcell death, sustained ER stress leads to apoptosis.Proteasome and autophagy are two main proteindegradation systems. We hypothesize that concomi-tant inhibition of proteasome and autophagy in cancercells will induce enhanced ER stress by the accumula-tion of unfolded proteins, and result in pronouncedcytotoxicity. Actually, in myeloma cells, we demon-strated that macrolide antibiotics block autophagyflux and lead to sensitization to proteasome inhibitor,bortezomib, via ER stress-mediated CHOP induction.Recently, we further delineated the role of aggresomeas another target for ER stress-mediated apoptosis. Iam currently focusing on other hematologic malig-nancies including MPN in order to elucidate the roleof ER stress in biological and therapeutic aspects.Publications:

1) Moriya S, et al: Targeting the integrated networks ofaggresome formation, proteasome, and autophagypotentiates ER stress-mediated cell death in multiple


325

myeloma cells. Int J Oncol, 2015; 46: 474-486.2) Moriya S, et al: Macrolide antibiotics block autophagy

flux and sensitize to bortezomib via endoplasmicreticulum stress-mediated CHOP induction in myelomacells. Int J Oncol, 2013; 42: 1541-1550.

3) Hironori Harada (Associate Professor)The goal of my research is to clarify the molecular

mechanisms of MDS and to establish molecular-tar-geted therapies for it. My group has been analyzingvarious gene mutations in myeloid neoplasms. Wefound that mutations of the RUNX1 gene arefrequently detected in patients with myeloid neo-plasms. Furthermore, we have been investigating thepathogenesis of RUNX1 mutants in mouse and humanhematopoietic stem cells (HSC). As part of this effort,we have reported that RUNX1 mutants induce MDSin collaboration with other gene abnormalities in amouse BMT model. We are currently analyzing geneabnormalities including in the RUNX family, RNAsplicing machinery and epigenetic regulators in thepathogenesis of various types of MDS. Nationwideresearch of familial MDS is ongoing.Publications:

1) Harada H, et al: Recent advances in myelodysplasticsyndromes: Molecular pathogenesis and its implicationsfor targeted therapies. Cancer Sci, 2015; 106: 329-336.

4) Masaru Tanaka (Associate Professor)There are many disease entities in lymphoma, but

only a few standard treatments for them. The missionof our group is to establish standard treatments forvarious types of them, especially for Hodgkinlymphoma and B-cell lymphomas. Our department isa member of the Lymphoma Study Group of theJapan Clinical Oncology Group (JCOG-LSG), whichhas conducted many clinical trials for various types oflymphoma. We are going to achieve our mission byparticipating in clinical trials of JCOG-LSG.

5) Makoto Sasaki (Associate Professor)My group has been investigating lymphoid malig-

nancies, especially focusing on MM and its clinicalfeatures. We aim to clarify (1) ideal chemotherapy forelderly myeloma patients in Japan, (2) clinical fea-tures of various infections and their countermeasuresand (3) new diagnostic assays for MM. We estab-lished a multicenter multiple myeloma study group,the“Kanto-Tohoku MM Conference”(KT-MM),and have been continuously undertaking researchand clinical studies around myeloma.

6) Yasuharu Hamano (Associate Professor)We have been performing hematopoietic stem cell

transplantation medicine. Our group aims to improvetreatment outcome. Graft-versus-host diseases (GVHD)remain a major contributor to transplantation-relateddeaths. Nevertheless, optimal GVHD prophylaxis incord blood transplantation (CBT) is not obvious. Inour group, mycophenolate mofetil (MMF) wasemployed for GVHD prophylaxis in combination withcalcineurin inhibitor. We found that MMF enables

faster engraftment and causes less mucositis thanmethotrexate. MMF may be a feasible option forGVHD prophylaxis in CBT. We are currentlyanalyzing the optimal MMF dose and simple surro-gate parameters for therapeutic drug monitoring.

7) Jun Ando (Associate Professor)I am interested in immunotherapy and gene

therapy for lymphoma. My current research focuseson cytotoxic T lymphocyte (CTL) immunotherapyfor lymphoma, as I was working as a postdoc of Prof.Rooney at Baylor College of Medicine. I learned howto make antigen-specific CTL, evaluate T-cellfunctions and to utilize these T cells for clinicaltherapy. About 30% of lymphomas in immunocompe-tent individuals carry the Epstein-Barr virus (EBV)genome and express four of about 90 potential viralantigens. We have targeted LMP1 and LMP2 fortreatment. We are currently planning a clinical trialusing LMP-specific CTL for EBV-associated lym-phoma.

8) Tomoiku Takaku (Associate Professor)My research project involves analyzing the role of

heparan sulfate proteoglycans (HSPG) in hemato-poietic stem cell niche systems. All blood cells areproduced by HSC, and the self-renewal of HSC isregulated by the signal from niche cells and signalingmolecules included in the extracellular matrix(ECM). Among ECM components, HSPG are crucialcontrollers of the structural and functional organiza-tion of the bone marrow niche. We have beeninvestigating the influence on hematopoiesis of a lackof HSPG in specific niche cells. It is considered thatthe eradication of leukemic stem cells is difficult bythe current therapy. The final goal of our research isto eradicate leukemic stem cells through the analysisof hematopoietic niche systems.Publications:

1) Takaku T, et al: Hematopoiesis in 3 dimensions: humanand murine bone marrow architecture visualized byconfocal microscopy. Blood, 2010; 116: e41-55.

9) Hajime Yasuda (Associate Professor)My research focuses on anemia attributed to

vitamin B6 (VB6) deficiency in post-pancreaticoduo-denectomy (PD) patients. VB6 deficiency can theo-retically occur after PD because of malabsorption.VB6 deficiency causes anemia due to the impairmentof heme synthesis. We recently reported two cases ofpost-PD patients with anemia due to VB6 deficiency,and this anemia resolved in both cases upon thesupplementation of VB6. Anemia has been reportedto be prevalent in long-term survivors of PD. We arecurrently planning to investigate VB6 levels alongwith other micronutrients necessary for hematopoie-sis in long-term survivors of PD at our institution.Publications:

1) Yasuda H, et al: Anemia attributed to vitamin B6deficiency in post-pancreaticoduodenectomy patients.Pancreatology, 2015; 15: 81-83.

Publications from Juntendo University Graduate School of Medicine, 2013 [ 1/6]

Department of Microbiology & Department of Infec-

tion Control Science

<Original Articles>

＊ 1）Fukuda M, Ushio H, Kawasaki J, Niyonsaba F,

Takeuchi M, Baba T, Hiramatsu K, Okumura

K, Ogawa H: Expression and functional char-

acterization of retinoic acid-inducible gene-I-

like receptors of mast cells in response to

viral infection. J Innate Immun, 2013; 5: 163-

173.

2）Katayama Y, Baba T, Sekine M, Fukuda M,

Hiramatsu K: Beta-hemolysin promotes skin

colonization by Staphylococcus aureus. J Bac-

teriol, 2013; 195: 1194-1203.

3）Kaito C, Saito Y, Ikuo M, Omae Y, Mao H,

Nagano G, Fujiyuki T, Numata S, Han X,

Obata K, Hasegawa S, Yamaguchi H, Ino-

kuchi K, Ito T, Hiramatsu K, Sekimizu K:

Mobile genetic element SCCmec-encoded

psm-mec RNA suppresses translation of

agrA and attenuates MRSA virulence. PLoS

Pathog, 2013; 9: e1003269.

4）Uehara Y, Kuwahara-Arai K, Hori S, Kikuchi

K, Yanai M, Hiramatsu K: Investigation of

nasal meticillin-resistant Staphylococcus aur-

eus carriage in a haemodialysis clinic in

Japan. J Hosp Infect, 2013; 84: 81-84.

＊ 5）Notake S, Matsuda M, Tamai K, Yanagisawa

H, Hiramatsu K, Kikuchi K: Detection of IMP

metallo-β-lactamase in carbapenem-nonsus-

ceptible Enterobacteriaceae and non-glucose-

fermenting Gram-negative rods by immuno-

chromatography assay. J Clin Microbiol, 2013;

51: 1762-1768.

＊ 6）Ohkushi D, Uehara Y, Iwamoto A, Misawa S,

Kondo S, Shimizu K, Hori S, Hiramatsu K: An

effective active surveillance method for con-

trolling nosocomial MRSA transmission in a

Japanese hospital. J Infect Chemother, 2013;

19: 871-875.

7）Zhang M, Ito T, Li S, Misawa S, Kondo S,

Miida T, Ohsaka A, Hiramatsu K: Analysis of

Staphylococcal cassette chromosome mec in

BD GeneOhm MRSA assay negative strains.

AntimicrobAgents Chemother, 2013; 57: 2890-

2891.

8）Lulitanond A, Ito T, Li S, Han X, Ma XX,

Engchanil C, Chanawong A, Wilailuckana C,

Jiwakanon N, Hiramatsu K: ST9 MRSA

strains carrying a variant of type IX SCCmec

identified in the Thai community. BMC Infect

Dis, 2013; 13: 214.

＊ 9）AibaY, KatayamaY, HishinumaT,Murakami-

Kuroda H, Cui L, Hiramatsu K: Mutation of

RNA polymerase β-subunit gene promotes

heterogeneous-to-homogeneous conversion of

β-lactam resistance in methicillin-resistant

Staphylococcus aureus. Antimicrob Agents

Chemother, 2013; 57: 4861-4871.

10）Matsuo M, Cui L, Kim J, Hiramatsu K: Com-

prehensive identification of mutations respon-

sible for heterogeneous vancomycin-inter-

mediate Staphylococcus aureus (hVISA)-to-

VISA conversion in laboratory-generated

VISA strains derived from hVISA clinical

strain Mu3. Antimicrob Agents Chemother,

2013; 57: 5843-5853.

11）Tomoyasu T, Imaki H, Masuda S, Okamoto A,

Kim H, Waite RD, Whiley RA, Kikuchi K,

Hiramatsu K, Tabata A, Nagamune H: LacR

mutations are frequently observed in Strepto-

coccus intermedius and are responsible for

increased intermedilysin production and viru-

lence. Infect Immun, 2013; 81: 3276-3286.

12）Tanaka Y, Sato Y, Sasaki T: Suppression of

coronavirus replication by cyclophilin inhibi-

tors. Viruses, 2013; 5: 1250-1260.

13）Oka F, Naito T, Oike M, Saita M, Inui A,

Uehara Y, Mitsuhashi K, Isonuma H, Hisaoka

T, Shimbo T: Influence of smoking on HIV

infection among HIV-infected Japanese men.

326

Publication List


An asterisk (＊) denotes doctoral works by Japanese students.

A dugger (†) denotes doctoral works by non-Japanese students.

J Infect Chemother, 2013; 19: 542-544.

14）Nishizaki Y, Yamagami S, Joki Y, Takahashi S,

Sesoko M, Yamashita H, Yokoyama T, Uehara

Y, Daida H: Japanese features of native valve

endocarditis caused by coagulase-negative

staphylococci: case reports and a literature

review. Intern Med, 2013; 52: 567-572.

<Reviews>

1）Hiramatsu K, Ito T, Tsubakishita S, Sasaki T,

Takeuchi F, Morimoto Y, Katayama Y,

Matsuo M, Kuwahara-Arai K, Hishinuma T,

Baba T: Genomic basis for methicillin resist-

ance in Staphylococcus aureus. Infect Chemo-

ther, 2013; 45: 117-136.

2）Ito T, Tsubakishita S, Kuwahara K, Han X,

Hiramatsu K: Staphylococcal cassette chro-

mosome (SCC): a unique gene transfer

system in Staphylococci. In: Roberts AP,

Mullany P, eds. Bacterial Integrative Mobile

Genetic Elements. Austin: Landes Bioscience,

2013; 291-305.

3）Mariem BJ, Ito T, Zhang M, Jin J, Li S, Ilhem

BB, Adnan H, Han X, Hiramatsu K: Molecu-

lar characterization of methicillin-resistant

Panton-valentine leukocidin positive staphy-

lococcus aureus clones disseminating in

Tunisian hospitals and in the community.

BMC Microbiol, 2013; 13: 2.

Department of Molecular and Cellular Parasitology

<Original Articles>

1）Tanabe K, Jombart T, Horibe S, Palacpac N,

Honma H, Tachibana S, Nakamura M, Horii T,

Kishino H, Mita T: Plasmodium falciparum

mitochondrial genetic diversity exhibits isola-

tion-by-distance patterns supporting a sub-

Saharan African origin. Mitochondrion, 2013;

13: 630-636.

2）Hunja CW, Unger H, Ferreira P, Lumsden R,

Morris R, Aman R, Alexander C, Mita T,

Culleton R: Travellers as sentinels: Assaying

the worldwide distribution of polymorphisms

associated with artemisinin combination ther-

apy resistance in Plasmodium falciparum

using malaria cases imported into Scotland.

Int J Parasitol, 2013; 43: 885-889.

3）Khattak A, Vankatesan M, Jacob CG, Artimo-

vich EM, Nadeem MF, Nighat F, Hombhanje

F, Mita T, Malik SA, Plowe CV: A compre-

hensive survey of polymorphisms conferring

anti-malarial resistance in Plasmodium falci-

parum across Pakistan. Malar J, 2013; 12:

300.

4）Tanabe K, Mita T, Palacpac NM, Arisue N,

Tougan T, Kawai S, Jombart T, Kobayashi F,

Horii T: Within-population genetic diversity

of Plasmodium falciparum vaccine candidate

antigens reveals geographic distance from a

Central sub-Saharan African origin. Vaccine,

2013; 31: 1334-1339.

5）Janwan P, Intapan PM, Yamasaki H, Laum-

maunwai P, Sawanyawisuth K, Wongkham C,

Tayapiwatana C, Kitkhuandee A, Lulitanond

V, Nawa Y, Maleewong W: Application of

recombinant Gnathostoma spinigerum matrix

metalloproteinase-like protein for serodiagno-

sis of human gnathostomiasis by immunoblot-

ting. Am J Trop Med Hyg, 2013; 89: 63-67.

6）Ilhan HD, Yaman A, Morishima Y, Sugiyama

H, Muto M, Yamasaki H, Hasegawa H, Lebe B,

Bajin MS: Onchocerca lupi infection in Tur-

key: A unique case of a rare human parasite.

Acta Parasitol, 2013; 58: 384-388.

7）Boonyasiri A, Cheunsuchon P, Srirabheebhat

P, Yamasaki H, Maleewong W, Intapan PM:

Sparganosis presenting as cauda equina syn-

drome with molecular identification of the

parasite in tissue sections. Korean J Parasitol,

2013; 51: 739-742.

8）Janwan P, Intapan PM, Yamasaki H, Laum-

maunwai P, Sawanyawisuth K, Wongkham C,

Tayapiwatana C, Kitkhuandee A, Lulitanond

V, Nawa Y, Maleewong W: A recombinant

matrix metalloproteinase protein from Gna-

thostoma spinigerum for serodiagnosis of

neurognathostomiasis. Korean J Parasitol,

2013; 51: 751-754.

9）Ishida H, Imai T, Suzue K, Hirai M, Taniguchi

T, Okada H, Suzuki T, Shimokawa C, Hisaeda

H: IL-23 protection against Plasmodium ber-

ghei infection in mice is partially dependent

on IL-17 from macrophages. Eur J Immunol,

2013; 43: 2696-2706.

10）Duan X, Imai T, Chou B, Tu L, Himeno K,

Suzue K, Hirai M, Taniguchi T, Okada H,

Shimokawa C, Hisaeda H: Resistance to

malaria by enhanced phagocytosis of erythro-

cytes in LMP7-deficient mice. PLoS One,


327

2013; 8: e59633.

11）Kondo H, Hirano S, Chiba S, Andika IB, Hirai

M, Maeda T, Tamada T: Characterization of

burdock mottle virus, a novel member of the

genus Benyvirus, and the identification of

benyvirus-related sequences in the plant and

insect genomes. Virus Res, 2013; 177: 75-86.

12）Hashimoto M, Enomoto M, Morales J, Kure-

bayashi N, Sakurai T, Hashimoto T, Nara T,

Mikoshiba K: Inositol 1, 4, 5-trisphosphate

receptor regulates replication, differentiation,

infectivity and virulence of the parasitic

protist Trypanosoma cruzi. Mol Microbiol,

2013; 87: 1133-1150.

13）Balogun EO, Inaoka DK, Shiba T, Kido Y,

Nara T, Aoki T, Honma T, Tanaka A, Inoue

M, Matsuoka S, Michels PA, Harada S, Kita K:

Biochemical characterization of highly active

Trypanosoma brucei gambiense glycerol

kinase, a promising drug target. J Biochem,

2013; 154: 77-84.

14）Vicco MH, Ferini F, Rodeles L, Cardona P,

Bontempi I, Lioi S, Beloscar J, Nara T, Marcipar

I, Bottasso OA: Assessment of cross-reactive

host-pathogen antibodies in patients with

different stages of chronic Chagas disease. Rev

Esp Cardiol, 2013; 66: 791-796.

15）Shiba T, Kido Y, Sakamoto K, Inaoka DK,

Tsuge C, Tatsumi R, Takahashi G, Balogun

EO, Nara T, Aoki T, Honma T, Tanaka A,

Inoue M, Matsuoka S, Saimoto H, Moore AL,

Harada S, Kita K: Structure of the trypano-

some cyanide-insensitive alternative oxidase.

Proc Natl Acad Sci U S A, 2013; 110: 4580-

4585.

<Reviews>

1）Yamasaki H: Current status and perspec-

tives of cysticercosis and taeniasis in Japan.

Korean J Parasitol, 2013; 51: 19-29.

Department of Host Defense and Biochemical

Research

<Original Articles>

1）Ochiai T, Nishimura K, Watanabe T, Kitajima

M, Nakatani A, Inou T, Shibata H, Sato T,

Kishine K, Seo S, Okubo S, Futagawa S,

Mashiko S, Nagaoka I: Serum iron levels as a

new biomarker in chemotherapy with leuco-

vorin and fluorouracil plus oxaliplatin or

leucovorin and fluorouracil plus irinotecan,

with or without molecularly-targeted drugs.

Mol Clin Oncol, 2013; 1: 805-810.

2）Koikawa N, Aoki E, Suzuki Y, Sakuraba K,

Nagaoka I, Aoki K, Shimmura Y, Sawaki K:

Wheat gluten hydrolysate affects race per-

formance in the triathlon. Biomed Rep, 2013;

1: 646-650.

3）Kumakura S, Yamaguchi K, Sugasawa Y,

Murakami T, Kikuchi T, Inada E, Nagaoka I:

Effects of nitrous oxide on the production of

cytokines and chemokines by the airway epi-

thelium during anesthesia with sevoflurane

and propofol. Mol Med Rep, 2013; 8: 1643-

1648.

＊ 4）Momomura R, Naito K, Igarashi M, Watari T,

Terakado A, Oike S, Sakamoto K, Nagaoka I,

Kaneko K: Evaluation of the effect of glucos-

amine administration on biomarkers of carti-

lage and bone metabolism in bicycle racers.

Mol Med Rep, 2013; 7: 742-746.

<Reviews>

1）Iba T, Hashiguchi N, Nagaoka I, Tabe Y,

Murai M: Neutrophil cell death in response to

infection and its relation to coagulation. J

Intensive Care, 2013; 1: 13.

2）Iba T, Nagaoka I, Boulat M: The anticoagu-

lant therapy for sepsis-associated dissemi-

nated intravascular coagulation. Thromb Res,

2013; 131: 383-389.

Department of Molecular and Cellular Biochemis-

tory

<Original Articles>

1）Matsunaga Y, Fukuyama S, Okuno T, Sasaki

F, Matsunobu T, Asai Y, Matsumoto K, Saeki

K, Oike M, Sadamura Y, Machida K, Nakanishi

Y, KuboM, Yokomizo T, Inoue H: Leukotriene

B4 receptor BLT2 negatively regulates aller-

gic airway eosinophilia. FASEB J, 2013; 27:

3306-3314.

2）Ohkubo H, Ito Y, Minamino T, Mishima T,

Hirata M, Hosono K, Shibuya M, Yokomizo T,

Shimizu T, Watanabe M, Majima M: Leuko-

triene B4 type-1 receptor signaling promotes

liver repair after hepatic ischemia/reperfu-

sion injury through the enhancement of mac-

rophage recruitment. FASEB J, 2013; 27:

3132-3143.

Publication List, 2013

328

3）Taketomi Y, Ueno N, Kojima T, Sato H,

Murase R, Yamamoto K, Tanaka S, Sakanaka

M, Nakamura M, Nishito Y, Kawana M,

Kambe N, Ikeda K, Taguchi R, Nakamizo S,

Kabashima K, Gelb MH, Arita M, Yokomizo

T, Nakamura M, Watanabe K, Hirai H, Naka-

mura M, Okayama Y, Ra C, Aritake K, Urade

Y, Morimoto K, Sugimoto Y, Shimizu T, Naru-

miya S, Hara S, Murakami M: Mast cell matu-

ration is driven via a group III phospholipase

A2-prostaglandin D2-DP1 receptor para-

crine axis. Nat Immunol, 2013; 14: 554-563.

＊ 4）Matsunobu T, Okuno T, Yokoyama C, Yoko-

mizo T: Thromboxane A synthase-indepen-

dent production of 12-hydroxyheptadecatri-

enoic acid, a BLT2 ligand. J Lipid Res, 2013;

54: 2979-2987.

5）Dugu L, Nakahara T, Wu Z, Uchi H, Liu M,

Hirano K, Yokomizo T: Neuronatin is related

to keratinocyte differentiation by up-regulat-

ing involucrin. J Dermatol Sci, 2013; 73: 225-

231.

6）Tojo T, Wang Q, Okuno T, Yokomizo T,

Kobayashi Y: Synthesis of (S, 5Z, 8E, 10E)-

12-Hydroxyheptadeca-5, 8, 10-trienoic Acid

(12S-HHT) and its Analogues. Synlett, 2013;

24: 1545-1548.

7）Komatsu K, Lee JY, Miyata M, Lim JH, Jono

H, Koga T, Xu H, Yan C, Kai H, Li JD: Inhi-

bition of PDE4B suppresses inflammation by

increasing expression of the deubiquitinase

CYLD. Nat Commun, 2013; 4: 1684.

Department of Immunology

<Original Articles>

1）Noto D, Sakuma H, Takahashi K, Saika R,

Saga R, Yamada M, Yamamura T, Miyake S:

Development of a culture system to induce

microglia-like cells from haematopoietic cells.

Neuropathol Appl Neurobiol (Epub ahead),

2013.

2）Chihara N, Aranami T, Oki S, Matsuoka T,

Nakamura M, Kishida H, Yokoyama K, Kuro-

iwa Y, Hattori N, Okamoto T, Murata M,

Toda T, Miyake S, Yamamura T: Plasma-

blasts as migratory IgG-producing cells in

the pathogenesis of neuromyelitis optica.

PLoS One, 2013; 8: e83036.

3）Di Penta A, Chiba A, Alloza I, Wyssenbach A,

Yamamura T, Villoslada P, Miyake S, Van-

denbroeck K: A trifluoromethyl analogue of

celecoxib exerts beneficial effects in neuroin-

flammation. PLoS One, 2013; 8: e83119.

4）Kuroda I, Inukai T, Zhang X, Kikuchi J, Furu-

kawa Y, Nemoto A, Akahane K, Hirose K,

Honna-Oshiro H, Goi K, Kagami K, Yagita H,

Tauchi T, Maeda Y, Sugita K: BCR-ABL

regulates death receptor expression for TNF-

related apoptosis-inducing ligand (TRAIL) in

Philadelphia chromosome-positive leukemia.

Oncogene, 2013; 32: 1670-1681.

5）Chabtini L, Mfarrej B, Mounayar M, Zhu B,

Batal I, Dakle PJ, Smith BD, Boenisch O,

Najafian N, Akiba H, Yagita H, Guleria I:

TIM-3 regulates innate immune cells to

induce fetomaternal tolerance. J Immunol,

2013; 190: 88-96.

6）Berrien-Elliott MM, Jackson SR, Meyer JM,

Rouskey CJ, Nguyen TL, Yagita H, Green-

berg P, DiPaolo RJ, Teague RM: Durable

adoptive immunotherapy for leukemia pro-

duced by manipulation of multiple regulatory

pathways of CD8 + T cell tolerance. Cancer

Res, 2013; 73: 605-616.

7）Zhou H, Ekmekcioglu S, Marks JW, Mohame-

dali KA, Asrani K, Phillips KK, Brown SA,

Cheng E, Weiss MB, Hittelman WN, Tran NL,

Yagita H, Winkles JA, Rosenblum MG: The

TWEAK receptor Fn14 is a therapeutic tar-

get in melanoma: immunotoxins targeting

Fn14 receptor for malignant melanoma treat-

ment. J Invest Dermatol, 2013; 133: 1052-

1062.

8）Baghdadi M, Nagao H, Yoshiyama H, Akiba

H, Yagita H, Dosaka-Akita H, Jinushi M:

Combined blockade of TIM-3 and TIM-4

augments cancer vaccine efficacy against

established melanomas. Cancer Immunol

Immunother, 2013; 62: 629-637.

9）Lewkowich IP, Lajoie S, Stoffers SL, Suzuki Y,

Richgels PK, Dienger K, Sproles AA, Yagita

H, Hamid Q, Wills-Karp M: PD-L2 modulates

asthma severity by directly decreasing den-

dritic cell IL-12 production. Mucosal Immu-

nol, 2013; 6: 728-739.

10）Nakatsuka A, Wada J, Iseda I, Teshigawara S,

Higashio K, Murakami K, Kanzaki M, Inoue K,

Terami T, Katayama A, Hida K, Eguchi J,


329

Ogawa D, Matsuki Y, Hiramatsu R, Yagita H,

Kakuta S, Iwakura Y, Makino H: Visceral

adipose tissue-derived serine proteinase

inhibitor inhibits apoptosis of endothelial cells

as a ligand for the cell-surface GRP78/volt-

age-dependent anion channel complex. Circ

Res, 2013; 112: 771-780.

11）Ishida W, Fukuda K, Harada Y, Sumi T,

Taguchi O, Tsuda M, Yagita H, Fukushima A:

Oral administration of Ag suppresses Ag-

induced allergic conjunctivitis in mice: crit-

ical timing and dose of Ag. Br J Ophthalmol,

2013; 97: 492-497.

12）Knight DA, Ngiow SF, Li M, Parmenter T,

Mok S, Cass A, Haynes NM, Kinross K, Yagita

H, Koya RC, Greber TG, Ribas A, McArthur

GA, Smyth MJ: Host immunity contributes to

the anti-melanoma activity of BRAF inhibi-

tors. J Cin Invest, 2013; 123: 1371-1381.

13）Xu D, Fu HH, Obar JJ, Park JJ, Tamada K,

Yagita H, Lefrancois L: A potential new

pathway for PD-L1 costimulation of the CD8

T cell response to Listeria monocytogenes

infection. PLoS One, 2013; 8: e56539.

14）Gottschalk C, Damuzzo V, Gotot J, Krokzek

RA, Yagita H, Murphy KM, Knolle PA, Lud-

wig-Portugall I, Kurts C: Batf3-dependent

dendritic cells in the renal lymph node induce

tolerance against circulating antigens. J Am

Soc Nephrol, 2013; 24: 543-549.

15）Mochizuki K, Xie F, He S, Tong Q, Liu Y,

Mochizuki I, Guo Y, Kato K, Yagita H, Mineishi

S, Zhang Y: Delta-like ligand 4 identifies a

previously uncharacterized population of

inflammatory dendritic cells that plays impor-

tant roles in eliciting allogeneic T cell responses

in mice. J Immunol, 2013; 190: 3772-3782.

16）Van der Werf N, Redpath NA, Azuma M,

Yagita H, TaylorMD: Th2 cell-intrinsic hypo-

responsiveness determines susceptibility to

helminth infection. PLoS Pathog, 2013; 9:

e1003215.

17）Riella LV, Yang J, Chock S, Safa K, Magee CN,

Vanguri V, Elyaman W, Lahoud Y, Yagita H,

Abdi R, Najafian N, Medina-Pestana JO,

Chandraker A: Jagged2 signaling promotes

IL-6-dependent transplant rejection. Eur J

Immunol, 2013; 43: 1449-1458.

18）Welten SP, Redeker A, Franken KL, Benedict

CA, Yagita H, Wensveen FM, Borst J, Melief

CJ, van Lier RA, van Gisbergen KP, Arens R:

CD27/CD70 costimulation controls T cell

immunity during acute and persistent cyto-

megalovirus infection. J Virol, 2013; 87: 6851-

6865.

19）Riella LV, Dada S, Chabtini L, Smith B, Huang

L, Dakle P, Mfarrej B, DʼAddio F, Adams LT,

Kochupurakkal N, Vergani A, Fiorina P,

Mellor AL, Sharpe AH, Yagita H, Guleria I:

B7h (ICOS-L) maintains tolerance at the

fetomaternal interface. Am J Pathol, 2013;

182: 2204-2213.

20）Yasuda S, Sho M, Yamato I, Yoshiji H, Waka-

tsuki K, Nishiwada S, Yagita H, Nakajima Y:

Simultaneous blockade of programmed death

1 and vascular endothelial growth factor

receptor 2 (VEGFR2) induces synergistic

anti-tumor effect in vivo. Clin Exp Immunol,

2013; 172: 500-506.

21）Matsumoto A, Kanai T, Mikami Y, Chu PS,

Nakamoto N, Ebinuma H, Saito H, Sato T,

Yagita H, Hibi T: IL-22-producing RORgt-

dependent innate lymphoid cells play a novel

protective role in murine acute hepatitis.

PLoS One, 2013; 8: e62853.

22）Shimmura-Tomita M, Wang M, Taniguchi H,

Akiba H, Yagita H, Hori J: Galectin-9-medi-

ated protection from allo-specific T cells as a

mechanism of immune privilege of corneal

allografts. PLoS One, 2013; 8: e63620.

23）Caiado F, Carvaiho T, Rosa I, Remedio L, Costa

A, Matos J, Heissig B, Yagita H, Hattori K, da

Silva JP, Fidalgo P, Dias Pereira A, Dias S:

Bone marrow-derived CD11b + Jagged2 +

cells promote epithelial-to-mesenchymal tran-

sition and metastasization in colorectal cancer.

Cancer Res, 2013; 73: 4233-4246.

24）Zhou H, Hittelman WN, Yagita H, Cheung LH,

Martin SS, Winkles JA, Rosenblum MG:

Antitumor activity of a humanized, bivalent

immunotoxin targeting Fn14-positive solid

tumors. Cancer Res, 2013; 73: 4439-4450.

25）Vahl JC, Heger K, Knies N, Hein MY, Boon L,

Yagita H, Polic B, Schmidt-Supprian M: NKT

cell-TCR expression activates conventional

T cells in vivo, but is largely dispensable for

mature NKT cell biology. PLoS Biol, 2013; 11:

e1001589.


330

26）Hayashi A, Sato T, Kamada N, Mikami Y,

Matsuoka K, Hisamatsu T, Hibi T, Roers A,

Yagita H, Ohteki T, Yoshimura A, Kanai T: A

single strain of Clostridium butyricum indu-

ces intestinal IL-10-producing macrophages

to suppress acute experimental colitis in

mice. Cell Host Microbe, 2013; 13: 711-722.

27）Refaat A, Abdelhamed S, Yagita H, Inoue H,

Yokoyama S, Hayakawa Y, Saiki I: Berberine

enhances tumor necrosis factor-related apop-

tosis-inducing ligand-mediated apoptosis in

breast cancer. Oncol Lett, 2013; 6: 840-844.

28）Jinushi M, Yagita H, Yoshiyama H, Tahara H:

Putting the brakes on anticancer therapies:

suppression of innate immune pathways by

tumor-associated myeloid cells. Trends Mol

Med, 2013; 19: 536-545.

29）Simpson TR, Li F, Montalvo-Ortiz W, Sepul-

veda MA, Bergerhoff K, Arce F, Roddie C,

Henry JY, Yagita H, Wolchok JD, Peggs KS,

Ravetch JV, Allison JP, Quezada SA: Fc-

dependent depletion of tumor-infilatrating

regulatory T cells co-defines the efficacy of

anti-CTLA-4 therapy against melanoma. J

Exp Med, 2013; 210: 1695-1710.

30）Hirsova P, Ibrahim SH, Bronk SF, Yagita H,

Gores GJ: Vismodegib suppresses TRAIL-

mediated liver injury in a mouse model of

nonalcoholic steatohepatitis. PLoS One, 2013;

8: e70599.

31）Kawahara T, Toso C, Yamaguchi K, Cader S,

Douglas DN, Nourbakhsh M, Lewis JT,

Churchill TA, Yagita H, Kneteman NM:

Additive effect of sirolimus and anti-death

receptor 5 agonistic antibody against hepato-

cellular carcinoma. Liver Int, 2013; 33: 1441-

1448.

32）Hanazawa A, Hayashizaki K, Shinoda K,

Yagita H, Okumura K, Lohning M, Hara T,

Tani-ichi S, Ikuta K, Eckes B, Radbruch A,

Tokoyoda K, Nakayama T: CD49b-depend-

ent establishment of T helper cell memory.

Immunol Cell Biol, 2013; 91: 524-531.

33）Overstreet MG, Gaylo A, Angermann BR,

Hughson A, Hyun YM, Lambert K, Acharya

M, Billroth-Maclurg AC, Rosenberg AF,

Topham DJ, Yagita H, Kim M, Lacy-Hulbert

A, Meier-SchellersheimM, Fowell DJ: Inflam-

mation-induced interstitial migration of effec-

tor CD4+ T cells is dependent on integrin aV.

Nat Immunol, 2013; 14: 949-958.

34）Lirdprapamongkol K, Sakurai H, Abdelhamed

S, Yokoyama S, Maruyama T, Athikomkulchai

S, Viriyaroj A, Awale S, Yagita H, Ruchirawat

S, Svasti J, Saiki I: A flavonoid chrysin sup-

presses hypoxic survival and metastatic

growth of mouse breast cancer cells. Oncol

Rep, 2013; 30: 2357-2364.

35）Foks AC, Ran IA, Wasserman L, Frodermann

V, Ter Borg MN, de Jager SC, van Santbrink

PJ, Yagita H, Akiba H, Bot I, Kuiper J, van

Puijvelde GH: T-cell immunoglobulin and

mucin domain 3 acts as a negative regulator

of atherosclerosis. Arterioscler Thromb Vasc

Biol, 2013; 33: 2558-2565.

36）Ohyagi H, Onai N, Sato T, Yotsumoto S, Liu J,

Akiba H, Yagita H, Atarashi K, Honda K,

Roers A, Muller W, Kurabayashi K, Hosoi-

Amaike M, Takahashi N, Hirokawa M, Matsu-

shima K, Sawada K, Ohteki T: Monocyte-

derived dendritic cells perform hemophago-

cytosis to fine-tune excessive immune

responses. Immunity, 2013; 39: 584-598.

37）Saha A, Aoyama K, Taylor PA, Koehn BH,

Veenstra RG, Panoskaltsis-Mortari A, Munn

DH, Murphy WJ, Azuma M, Yagita H, Fife

BT, Sayegh MH, Najafian N, Socie G, Ahmed

R, Freeman GJ, Sharpe AH, Blazar BR: Host

programmed death ligand-1 is dominant over

programmed death ligand-2 expression in

regulating graft-versus-host disease lethal-

ity. Blood, 2013; 122: 3062-3073.

＊38）Abe Y, Kamachi F, Kawamoto T, Makino F,

Ito J, Kojima Y, Moustapha AE, Usui Y,

Yagita H, Takasaki Y, Okumura K, Akiba H:

TIM-4 has dual function in the induction and

effector phases of murine arthritis. J Immu-

nol, 2013; 191: 4562-4572.

39）Foks AC, van Puijvelde GH, Bot I, Ter Borg

MN, Habets KL, Johnson JL, Yagita H, van

Berke TJ, Kuiper J: Interruption of the

OX40-OX40 ligand pathway in LDL recep-

tor-deficient mice causes regression of athe-

rosclerosis. J Immunol, 2013; 191: 4573-4580.

40）Traore DA, Brennan AJ, Law RH, Dogovski

C, Perugini MA, Lukoyanova N, Leung EW,

Norton RS, Lopez JA, Browne KA, Yagita H,

Lloyd GJ, Ciccone A, Verschoor S, Trapani


331

JA, Whisstock JC, Voskoboinik I: Defining

the interaction of perforin with calcium and

the phospholipid membrane. Biochem J, 2013;

456: 323-335.

41）Ma J, Bang B-R, Lu J, Eun S-Y, Otsuka M,

Croft M, Tobias P, Han J, Takeuchi O, Akira

S, Karin M, Yagita H, Kang YJ: The TNF

family member 4-1BBL sustains inflamma-

tion by interacting with TLR signaling com-

ponents during late-phase activation. Sci

Signal, 2013; 6: ra87.

42）Baghdadi M, Yoneda A, Yamashita T, Nagao

H, Komohara Y, Nagai S, Akiba H, Foretz M,

Yoshiyama H, Kinoshita I, Dosaka-Akita H,

Takeya M, Viollet B, Yagita H, Jinushi M:

TIM-4 glycoprotein-mediated degradation of

dying tumor cells by autophagy leads to

reduced antigen presentation and increased

immune tolerance. Immunity, 2013; 39: 1070-

1081.

43）Ashida H, Nakano H, Sasakawa C: Shigella

IpaH0722 E3 ubiquitin ligase effector targets

TRAF2 to inhibit PKC-NF-κB activity in

invaded epithelial cells. PLoS Pathog, 2013; 9:

e1003409.

44）Ly DL, Waheed F, Lodyga M, Speight P,

Masszi A, Nakano H, Hersom M, Pedersen

SF, Szaszi K, Kapus A: Hyperosmotic stress

regulates the distribution and stability of

myocardin-related transcription factor, a key

modulator of the cytoskeleton. Am J Physiol

Cell Physiol, 2013; 304: 115-127.

45）Shindo R, Kakehashi H, Okumura K, Kumagai

Y, Nakano H: Critical contribution of oxidative

stress to TNFα-induced necroptosis down-

stream of RIPK1 activation. Biochem Biophys

Res Commun, 2013; 436: 212-216.

46）Speight P, Nakano H, Kelley TJ, Hinz B,

Kapus A: Differential topical susceptibility to

TGFβ in intact and injured regions of the

epithelium: key role in myofibroblast transi-

tion. Mol Biol Cell, 2013; 24: 3226-3236.

47）Wang L, Lu Y, Guan H, Jiang D, Guan Y,

Zhang X, Nakano H, Zhou Y, Zhang Y, Yang

L, Li H: Tumor necrosis factor receptor-asso-

ciated factor 5 is an essential mediator of

ischemic brain infarction. J Neurochem, 2013;

126: 400-414.

＊48）Hosoya S, Ikejima K, Takeda K, Arai K, Ishi-

kawa S, Yamagata H, Aoyama T, Kon K,

Yamashina S, Watanabe S: Innate immune

responses involving natural killer and natural

killer T cells promote liver regeneration after

partial hepatectomy in mice. Am J Physiol

Gastrointest Liver Physiol, 2013; 304: G293-

299.

49）Matsusita N, Aruga A, Inoue Y, Kotera Y,

Takeda K, Yamamoto M: Phase I clinical trial

of a peptide vaccine combined with tegafur-

uracil plus leucovorin for treatment of

advanced or recurrent colorectal cancer.

Oncol Rep, 2013; 29: 951-959.

50）Suzuki H, Fukuhara M, Yamaura T, Mutoh S,

Okabe N, Yaginuma H, Hasegawa T, Yonechi

A, Osugi J, Hoshino M, Kimura T, Higuchi M,

Shio Y, Ise K, Takeda K, Gotoh M: Multiple

therapeutic peptide vaccines consisting of

combined novel cancer testis antigens and

anti-angiogenic peptides for patients with

non-small cell lung cancer. J Trans Med,

2013; 11: 97.

51）Takahashi K, Takeda K, Saiki I, Irimura T,

Hayakawa Y: Functional roles of tumor

necrosis factor-related apoptosis-inducing

ligand-DR5 interaction in B16F10 cells by

activating the nuclear factor-kB pathway to

induce metastatic potential. Cancer Sci, 2013;

104: 558-562.

52）Aruga A, Takeshita N, Kotera Y, Okuyama R,

Matsushita N, Ohta T, Takeda K, Yamamoto

M: Long-term vaccination with multiple

peptides derived from cancer-testis antigens

can maintain a specific T-cell response and

achieve disease stability in advanced biliary

tract cancer. Clin Cancer Res, 2013; 19: 2224-

2231.

53）Asahara S, Takeda K, Yamao K, Maguchi H,

Yamaue H: Phase I/II clinical trial using

HLA-A24-restricted peptide vaccine derived

from KIF20A for patients with advanced

pancreatic cancer. J Transl Med, 2013; 11:

291.

54）Okuyama R, Aruga A, Hatori T, Takeda K,

Yamamoto M: Immunological responses to a

multi-peptide vaccine targeting cancer-tes-

tis antigens and VEGFRs in advanced pancre-

atic cancer patients. Oncoimmunology, 2013;

2: e27010.


332

55）Yeung MY, McGrath MM, Nakayama M,

Shimizu T, Boenisch O, Magee CN, Abdoli R,

Akiba H, Ueno T, Turka LA, Najafian N:

Interruption of dendritic cell-mediated TIM-4

signaling induces regulatory T cells and

promotes skin allograft survival. J Immunol,

2013; 191: 4447-4455.

Department of Molecular Pathogenesis

<Original Articles>

† 1）Obulhasim G, Yasen M, Kajino K, Mogushi K,

Tanaka S, Mizushima H, Tanaka H, Arii S, Hino

O: Up-regulation of dbpA mRNA in hepato-

cellular carcinoma associated with metabolic

syndrome. Hapatol Int, 2013; 7: 215-225.

＊ 2）Ito M, Kajino K, Abe M, Fujimura T, Mineki

R, Ikegami T, Ishikawa T, Hino O: NP-1250,

an ABCG2 inhibitor, induces apoptotic cell

death in mitoxantrone-resistant breast carci-

noma MCF7 cells via a caspase-independent

pathway. Oncol Rep, 2013; 29: 1492-1500.

＊ 3）Osawa M, Kobayashi T, Okura H, Igarashi T,

Mizuguchi M, Hino O: TSC1 controls distri-

bution of actin fibers through its effect on

function of Rho family of small GTPases and

regulates cell migration and polarity. Plos

One, 2013; 8: e54503.

4）Nomura R, Fujii H, Abe M, Sugo H, Ishizaki Y,

Kawasaki S, Hino O: Mesothelin expression is

a prognostic factor in cholangiocellular carci-

noma. Int Surgery, 2013; 98: 164-169.

＊ 5）Okura H, Kobayashi T, Koike M, Ohsawa M,

Zhang D, Arai H, Uchiyama Y, Hino O:

Tuberin activates and controls the distribu-

tion of Rac1 via association with p62 and

ubiquitin through the mTORC1 signaling

pathway. Int J Oncology, 2013; 43: 447-456.

6）Mori T, Tajima K, Hirama M, Sato T, Kido K,

Iwakami S, Sasaki S, Iwase A, Shiomi K,

Maeda M, Hino O, Takahashi K: The N-ERC

index is a novel monitoring and prognostic

marker for advanced malignant pleural meso-

thelioma. J Thorac Dis, 2013; 5: 145-148.

7）Kawamata F, Homma S, Kamachi H, Einama

T, Kato Y, Tsuda M, Tanaka S, Maeda M,

Kajino K, Hino O, Takahashi N, Kamiyama T,

Nishihara H, Taketomi A, Todo S: C-ERC/

mesothelin provokes lymphatic invasion of

colorectal adenocarcinoma. J Gastroenterol,

Epub 2013 Mar 20. doi: 10.1007/s00535-013-

0773-6.

＊ 8）Hirohashi T, Igarashi K, Abe M, Maeda M,

Hino O: Retrospective analysis of large-scale

research screening of construction workers

for the early diagnosis of mesothelioma. Mol

Clin Oncol, Epub 2013 Oct 2. doi: 10.3892/

mco.2013.197.

＊ 9）Hirano S, Kakinuma S, Amasaki Y, Nishimura

M, Imaoka T, Fujimoto S, Hino O, Shimada Y:

Ikaros is a critical target during simultaneous

exposure to X-rays and N-ethyl-N-nitro-

sourea in mouse T-cell lymphomagenesis. Int

J Cancer, 2013; 132: 259-268.

＊10）Abe H, Mochizuki S, Ohara K, Ueno M, Ohiai

H, Kitagawa Y, Hino O, Sato H, Okada Y: Src

plays a key role in ADAM28 expression in

v-src-transformed epithelial cells and human

carcinoma cells. Am J Pathol, 2013; 183: 1667-

1678.

＊11）Kawai A, Kobayashi T, Hino O: Folliculin

regulates cyclin D1 expression through cis-

acting elements in the 3ʼ untranslated region

of cyclin D1 mRNA. Int J Oncol, 2013; 42:

1597-1604.

＊12）Kawano S, Lin Q, Amano H, Kaneko T,

Nishikawa K, Tsurui H, Tada N, Nishimura H,

Takai T, Shirai T, Takasaki Y, Hirose S:

Phenotype conversion from rheumatoid arthri-

tis to systemic lupus erythematosus by intro-

duction of Yaa mutation into FcγRIIB-defi-

cient C57BL/6 mice. Eur J Immunol, 2013; 43:

770-778.

†13）Xu M, Hou R, Sato-Hayashizaki A, Man R,

Zhu C, Wakabayashi C, Hirose S, Adachi T,

Tsubata T: Cd72(c) is a modifier gene that

regulates Fas(lpr)-induced autoimmune dis-

ease. J Immunol, 2013; 190: 5436-5445.

14）Tsurui H, Takahashi T, Matsuda Y, Sato-

Hayashizaki A, Hirose S: Exhaustive charac-

terization of TCR-pMHC binding energy

estimated by the string model and Miya-

zawa-Jernigan matrix. General Med, 2013; 2:

1-7.

15）Naito K, Watari T, Yasunari E, Yamano M,

Mogami A, Obayashi O, Kaneko K: Pulmo-

nary thrombosis associated with antidiuretic

hormone replacement therapy due to secon-

dary diabetes insipidus after traumatic brain


333

injury: a case report. Int J Surg Case Rep,

2013; 4: 94-97.

<Reviews>

1）Polanska UM, Orimo A: Carcinoma associ-

ated fibroblasts: non-neoplastic tumour-pro-

moting mesenchymal cells. J Cell Physiol,

2013; 228: 1651-1657.

2）Togo S, Polanska UM, Horimoto Y, Orimo A:

Carcinoma-associated fibroblasts are a prom-

ising therapeutic target. Cancers, 2013; 5:

149-169.

Department of Rheumatology

<Original Articles>

1）Yanagida M, Kawasaki M, Fujishiro M, Miura

M, Ikeda K, Nozawa K, Kaneko H, Morimoto S,

Takasaki Y, Ogawa H, Takamori K, Sekigawa

I: Serum proteome analysis in patients with

rheumatoid arthritis receiving therapy with

tocilizumab: an anti-interleukin-6 receptor

antibody. Biomed Res Int, 2013; 2013: 607137.

2）Anami A, Fukushima K, Takasaki Y, Sumida

T, Waguri M, Wake N, Murashima A: The

predictive value of anti-SS-A antibodies titra-

tion in pregnant women with fetal congenital

heart block. Mod Rheumatol, 2013; 23: 653-

658.

3）Nozawa K, Fujishiro M, Kawasaki M, Yama-

guchi A, Ikeda K, Morimoto S, Iwabuchi K,

Yanagida M, Ichinose S, Morioka M, Ogawa

H, Takamori K, Takasaki Y, Sekigawa I: Inhi-

bition of connective tissue growth factor

ameliorates disease in a murine model of

rheumatoid arthritis. Arthritis Rheum, 2013;

65: 1477-1486.

＊ 4）Kawano S, Lin Q, Amano H, Kaneko T,



Phenotype conversion from rheumatoid arthri-

tis to systemic lupus erythematosus by intro-

duction of Yaa mutation into FcγRIIB-defi-

cient G57BL/6 mice. Eur J Immunol, 2013; 43:

770-778.

5）Furukawa H, Kawasaki A, Shimada K, Matsui

T, Ikenaka T, Hashimoto A, Okazaki Y, Taka-

oka H, Futami H, Komiya A, Kondo Y, Ito S,

Hayashi T, Matsumoto I, Kusaoi M, Takasaki

Y, Nagai T, Hirohata S, Setoguchi K, Sudo A,

Nagaoka S, Kono H, Okamoto A, Chiba N,

Suematsu E, Fukui N, Hashimoto H, Sumida

T, Ono M, Tsuchiya N, Tohma S: Association

of a single nucleotide polymorphism in the

SH2D1A intronic region with systemic lupus

erythematosus. Lupus, 2013; 22: 497-503.

6）Shimane K, Kochi Y, Suzuki A, Okada Y, Ishii

T, Horita T, Saito K, Okamoto A, Nishimoto N,

Myouzen K, Kubo M, Hirakata M, Sumida T,

Takasaki Y, Yamada R, Nakamura Y, Kama-

tani N, Yamamoto K: An association analysis

of HLA-DRB1 with systemic lupus erythema-

tosus and rheumatoid arthritis in a Japanese

population: effects of *09: 01 allele on disease

phenotypes. Rheumatology, 2013; 52: 1172-

1182.

7）Murayama G, Ogasawara M, Nemoto T,

Yamada Y, Ando S, Minowa K, Kon T, Tada

K, Matsushita M, Yamaji K, Tamura N, Taka-

saki Y: Clinical miscount of involved joints

denotes the need for ultrasound complemen-

tation in usual practice for patients with

rheumatoid arthritis. Clin Exp Rheumatol,

2013; 31: 506-514.

8）Inami Y, Yamaji K, Sato M, Gohda T, Io H,

Nawata M, Hamada C, Takasaki Y, Tomino Y:

Effects of dialysis on the pharmacokinetics of

salazosulfapyridine. Rheumatol Int, 2013; 33:

535-539.

9）Nemoto T, Ogasawara M, Matsuki Y, Mura-

yama G, Yamada Y, Sugisaki N, Ando S,

Minowa K, Kon T, Tada K, Matushita M,

Yamaji K, Tamura N, Takasaki Y: Can

routine clinical measures predict ultrasound-

determined synovitis and remission in rheu-

matoid arthritis patients? Clin Exp Rheuma-

tol, 2013; 32: 54-60.

10）Abe Y, Kamachi F, Kawamoto T, Makino F,

Ito J, Kojima Y, Moustapha Ael D, Usui Y,

Yagita H, Takasaki Y, Okumura K, Akiba H:

TIM-4 has dual function in the induction and

effector phases of murine arthritis. J lmmunol,

2013; 191: 4562-4572.

11）Yamanishi Y, Ito-Ihara T, Nagao T, Uno K,

Kobayashi S, Muso E, Shane PY, Firestein GS,

Hashimoto H, Okazaki T, Suzuki K: Clinical

features of patients with anti-neutrophil

cytoplasmic autoantibodies targeting native

myeloperoxidase antigen. Mod Rheumatol,

2013; 23: 963-971.


334

12）Muso E, Okuzaki D, Kobayashi S, Iwasaki Y,

Sakurai MA, Ito A, Nojima H: Ficolin-1 is

up-regulated in leukocytes and glomeruli

from microscopic polyangiitis patients. Auto-

immunity, 2013; 46: 513-524.

13）Kawasaki A, Inoue N, Ajimi C, Sada KE,

Kobayashi S, Yamada H, Furukawa H,

Sumida T, Tohma S, Miyasaka N, Matsuo S,

Ozaki S, Hashimoto H, Makino H, Harigai M,

Tsuchiya N: Association of IRF5 polymor-

phism with MPO-ANCA-positive vasculitis

in a Japanese population. Genes Immun, 2013;

14: 527-529.

14）Kawakami T, Okudaira A, Okano T, Take-

uchi S, Kimura S, Soma Y, Ishizu A, Arimura

Y, Kobayashi S, Ozaki S: Treatment for

cutaneous arteritis patients with mononeuri-

tis multiplex and elevated C-reactive protein.

J Dermatol, 2013; 40: 955-961.

15）Matsuda J, Kaburaki T, Kobayashi S, Numaga

J: Treatment of recurrent anterior uveitis

with infliximab in patient with ankylosing

spondylitis. Jpn J Ophthalmol, 2013; 57: 104-

107.

16）Nagao T, Kusunoki R, Iwamura C, Kobayashi

S, Yumura W, Kameoka Y, Nakayama T,

Suzuki K: Correlation of interleukin-6 and

monocyte chemotactic protein-1 concentra-

tions with crescent formation and myeloper-

oxidase-specific anti-neutrophil cytoplasmic

antibody titer in SCG/Kj mice by treatment

with anti-interleukin-6 receptor antibody or

mizoribine. Microbiol Immunol, 2013; 57: 640-

650.

<Reviews>

1）Kobayashi S, Fujimoto S: Epidemiology of vas-

culitides: differences between Japan, Europe

and North America. Clin Exp Nephrol, 2013;

17: 611-614.

Atopy (Allergy) Research Center

<Original Articles>

1）Shirao K, Inoue M, Tokuda R, Nagao M, Yama-

guchi M, Okahata H, Fujisawa T:“Bitter

sweet”: a child case of erythritol-induced ana-

phylaxis. Allergol Int, 2013; 62: 269-271.

2）Sugiyama T, Kitamura M, Sugita K, Hisamoto

M, Okuda T, Nakao A: Grape seed extract

from“Koshu”cultivar antagonizes dioxin-

induced aryl hydrocarbon receptor activa-

tion. Am J Enol Viticult, 2013; 64: 146-151.

3）Luo XY, Takahara T, Kawai K, Fujino M,

Sugiyama T, Tsuneyama K, Tsukada K,

Nakae S, Zhong L, Li XK: IFN-γ deficiency

attenuates hepatic inflammation and fibrosis

in a steatohepatitis model induced by a

methionine and choline-deficient high fat

diet. Am J Physiol Gastrointest Liver Physiol,

2013; 305: G891-899.

＊ 4）Chen X, Takai T, Xie Y, Niyonsaba F,

Okumura K, Ogawa H: Human antimicrobial

peptide LL-37 modulates proinflammatory

responses induced by cytokine milieus and

double-stranded RNA in human keratino-

cytes. Biochem Biophys Res Commun, 2013;

433: 532-537.

5）Bian Z, Furuya N, Zheng D-M, Trejo JAO,

Tada N, Ezaki J, Ueno T: Ferulic acid induces

mTor inactivation in cultured mammalian

cells. Biological & Pharmaceutical Bulletin,

2013; 36: 120-124.

6）Nakazawa T, Khan AF, Yasueda H, Saito A,

Fukutomi Y, Takai T, Zaman K, Yunus M,

Takeuchi H, Iwata T, Akiyama K: Immuniza-

tion of rabbits with nematode Ascaris lumbri-

coides antigens induces antibodies cross-

reactive to house dust mite Dermatopha-

goides farinae antigens. Biosc Biotechnol Bio-

chem, 2013; 77: 145-150.

7）Takita E, Yokota S, Tahara Y, Hirao A, Aoki N,

Nakamura Y, Nakao A, Shibata S: Biological

clock dysfunction exacerbates contact hyper-

sensitivity in mice. Brit J Dermatol, 2013; 168:

39-46.

8）Caiado F, Carvalho T, Rosa I, Remédio L, Costa

A, Matos J, Heissig B, Yagita H, Hattori K, da

Silva JP, Fidalgo P, Pereira AD, Dias S: Bone

marrow-derived CD11b+Jagged2+ cells pro-

mote epithelial-to-mesenchymal transition and

metastasization in colorectal cancer. Cancer

Res, 2013; 73: 4233-4246.

9）Cermakian N, Lange T, Golombek D, Sarkar

D, Nakao A, Shibata S, Mazzoccoli G: Cross-

talk between the circadian clock circuitry and

the immune system. Chronobiol Int, 2013; 30:

870-888.

10）Yoon JH, Jung SM, Park SH, Kato M, Yama-

shita T, Lee IK, Sudo K, Nakae S, Han JS, Kim


335

OH, Oh BC, Sumida T, Kuroda M, Ju JH, Jung

KC, Park SH, Kim DK, Mamura M: Activin

receptor-like kinase5 inhibition suppresses

mouse melanoma by ubiquitin degradation of

Smad4, thereby derepressing eomesodermin

in cytotoxic T lymphocytes. EMBO Mol Med,

2013; 5: 1720-1739.

11）Kawano S, Lin Q, Amano H, Kaneko T,



Phenotype conversion from rheumatoid

arthritis to systemic lupus erythematosus by

introduction of Yaa mutation into FcγRIIB-

deficient C57BL/6 mice. Eur J Immunol, 2013;

43: 770-778.

12）Osada Y, Yamada S, Nabeshima A, Yamagishi

Y, Ishiwata K, Nakae S, Sudo K, Kanazawa T:

Heligmosomoides polygyrus infection reduces

severity of type 1 diabetes induced by multiple

low-dose streptozotocin in mice via STAT6-

and IL-10-independent mechanisms. Exp

Parasitol, 2013; 135: 388-396.

13）Shibui A, Nakae S, Watanabe J, Sato Y, Tolba

ME, Doi J, Shiibashi T, Nogami S, Sugano S,

Hozumi N: Screening of novel malaria DNA

vaccine candidates using full-length cDNA

library. Exp Parasitol, 2013; 135: 546-550.

14）Mashima R, Arimura S, Kajikawa S, Oda H,

Nakae S, Yamanashi Y: Dok adaptors play

anti-inflammatory roles in pulmonary homeo-

stasis. Genes Cells, 2013; 18: 56-65.

15）Koketsu R, Yamaguchi M, Suzukawa M,

Tanaka Y, Tashimo H, Arai H, Nagase H,

Matsumoto K, Saito H, Ra C, Yamamoto K,

Ohta K: Pretreatment with low levels of

FcεRI-crosslinking stimulation enhances

basophil mediator release. Int Arch Allergy

Immunol, 2013; 161 (Suppl 2): 23-31.

16）Takada E, Furuhata M, Nakae S, Ichijo H,

Sudo K, Mizuguchi J: Requirement of apopto-

sis-inducing kinase 1 for the induction of

bronchial asthma following stimulation with

ovalbumin. Int Arch Allergy Immunol, 2013;

162: 104-114.

17）Kasagi H, Kuhara T, Okada H, Sueyoshi N,

Kurihara H: Mesenchymal stem cell trans-

plantation to the mouse cochlea as a treat-

ment for childhood sensorineural hearing

loss. Int J Pediatr Otorhinolaryngol, 2013; 77:

936-942.

18）Sugimoto N, Yamaguchi M, Tanaka Y,

Nakase Y, Nagase H, Akiyama H, Ohta K:

The basophil activation test identified car-

minic acid as an allergen inducing anaphy-

laxis. J Allergy Clin Immunol Pract, 2013; 1:

197-199.

19）Kamijo S, Takeda H, Tokura T, Suzuki M,

Inui K, Hara M, Matsuda H, Matsuda A,

Oboki K, Ohno T, Saito H, Nakae S, Sudo K,

Suto H, Ichikawa S, Ogawa H, Okumura K,

Takai T: IL-33-mediated innate response

and adaptive immune cells contribute to

maximum responses of protease allergen-

induced allergic airway inflammation. J

Immunol, 2013; 190: 4489-4499.

＊20）Fukuda M, Ushio H, Kawasaki J, Niyonsaba F,




like receptors of mast cells in response to viral

infection. J Innate Immun, 2013; 5: 163-173.

21）Aoki R, Kawamura T, Goshima F, Ogawa Y,

Nakae S, Nakao A, Moriishi K, Nishiyama Y,

Shimada S: Mast cells play a key role in host

defense against herpes simplex virus infec-

tion through TNF-α and IL-6 production. J

Invest Dermatol, 2013; 133: 2170-2179.

22）Niyonsaba F, Madera L, Afacan N, Okumura

K, Ogawa H, Hancock REW: The innate

defense regulator peptides IDR-HH2, IDR-

1002 and IDR-1018 modulate human neutro-

phil functions. J Leukoc Biol, 2013; 94: 159-

170.

23）Zhu Y, Ohba T, Ando T, Fujita K, Koyama K,

Nakamura Y, Katoh R, Haro H, Nakao A:

Endogenous TGF-β activity limits TSLP

expression in the intervertebral disc tissue by

suppressing NF-κB activation. J Orthop Res,

2013; 31: 1144-1149.

＊24）Hara M, Yokoyama H, Fukuyama K, Kita-

mura N, Shimokawa N, Maeda K, Kanada S,

Ito T, Usui Y, Ogawa H, Okumura K, Nishi-

yama M, Nishiyama C: Transcriptional regu-

lation of the mouse CD11c promoter by AP-1

complex with JunD and Fra2 in dendritic

cells. Mol Immunol, 2013; 53: 295-301.

25）Koike M, Tanida I, Nanao T, Tada N, Iwata

J-I, Ueno T, Kominami E, Uchiyama Y:


336

Enrichment of GABARAP relative to LC3 in

the axonal initial segments of neurons. PLoS

One, 2013; 8: e63568.

26）Miyajima M, Nakajima M, Motoi Y, Moriya M,

Sugano H, Ogino I, Nakamura E, Tada N,

Kunichika M, Arai H: Leucine-rich α2-glyco-

protein is a novel biomarker of neurodegener-

ative disease in human cerebrospinal fluid

and causes neurodegeneration in mouse

cerebral cortex. PLoS One, 2013; 8: e74453.

＊27）Nakanishi W, Yamaguchi S, Matsuda A, Suzu-

kawa M, Shibui A, Nambu A, Kondo K, Suto

H, Saito H, Matsumoto K, Yamasoba T, Nakae

S: IL-33, but not IL-25, is crucial for the

development of house dust mite antigen-

induced allergic rhinitis. PLoS One, 2013; 8:

e78099.

28）Nei Y, Obata-Ninomiya K, Tsutsui H, Ishi-

wata K, Miyasaka M, Matsumoto K, Nakae S,

Kanuka H, Inase N, Karasuyama H: GATA-1

regulates the generation and function of

basophils. Proc Natl Acad Sci USA, 2013; 110:

18620-18625.

<Reviews>

1）Nakae S, Morita H, Ohno T, Arae K, Matsu-

moto K, Saito H: Role of interleukin-33 in

innate-type immune cells in allergy. Allergol

Int, 2013; 62: 13-20.

<Books>

1）Takai T: Mite endopeptidase 1. In: Rawlings

ND, Salvesen GS, eds. Handbook of Proteo-

lytic Enzymes. UK, Oxford: Academic Press,

2013; 1957-1963.

2）Takai T: Serine endopeptidase allergens

from Dermatophagoides species. In: Raw-

lings ND, Salvesen GS, eds. Handbook of

Proteolytic Enzymes. UK, Oxford: Academic

Press, 2013; 3055-3060.

Department of Dermatology and Allergology

<Original Articles>

1）Kurosawa M, Takagi A, Tamakoshi A, Kawa-

mura T, Inaba Y, Yokoyama K, Kitajima Y,

Aoyama Y, Iwatsuki K, Ikeda S: Epidemiology

and clinical characteristics of bullous congeni-

tal ichthyosiform erythroderma (keratinolytic

ichthyosis) in Japan: results from a nation-

wide survey. J Am Acad Dermatol, 2013; 68:

278-283.

2）Hiruma M, Kano R, Sugita T, Mochizuki T,

Hasegawa A, Hiruma M: Urease gene of

Trichophyton rubrum var. raubitschekii. J

Deramatol, 2013; 40: 111-113.

3）Ikeda S, Takahashi H, Suga Y, Eto H, Etoh T,

Okuma K, Takahashi K, Kanbara T, Seishima

M, Morita A, Imai Y, Kanekura T: Therapeu-

tic depletion of myeloid lineage leukocytes in

patients with generalized pustular psoriasis

indicates a major role for neutrophils in the

immunopathogenesis of psoriasis. J Am Acad

Dermatol, 2013; 68: 609-617.

4）Fukai T, Hiruma M (Masataro), Ogawa Y,

Ikeda S, Ikeda H, Sano A, Makimura K: A

case of phaeohyphomycosis caused by exo-

phiala oligosperma successfully treated with

local hyperthermia. Med Mycol J, 2013; 54:

297-301.

5）Ohtsuki A, Hasegawa T, Komiyama E, Takagi

A, Kawasaki J, Ikeda S: 308-nm excimer lamp

for the treatment of alopecia areata: clinical

trial on 16 cases. Indian J Dermatol, 2013; 58:

326.

6）Kano R, Anzawa K, Mochizuki T, Nishimoto

K, Hiruma M, Kamata H, Hasegawa A: Sporo-

thrix schenckii (sensu strict S. globosa)

mating type 1-2 (MAT1-2) gene. J Derma-

tol, 2013; 40: 726-730.

7）Chen X, Takai T, Xie Y, Niyonsaba F, Oku-

mura K, Ogawa H: Human antimicrobial

peptide LL-37 modulates proinflammatory

responses induced by cytokine milieus and

double-stranded RNA in human keratino-

cytes. Biochem Biophys Res Commun, 2013;

433: 532-537.

8）Kamijo S, Takeda H, Tokura T, Suzuki M,

Inui K, Hara M, Matsuda H, Matsuda A,

Oboki K, Ohno T, Saito H, Nakae S, Sudo K,

Suto H, Ichikawa S, Ogawa H, Okumura K,

Takai T: IL-33-mediated innate response

and adaptive immune cells contribute to

maximum responses of protease allergen-

induced allergic airway inflammation. J

Immunol, 2013; 190: 4489-4499.

9）Fukuda M, Ushio H, Kawasaki J, Niyonsaba F,




like receptors of mast cells in response to viral


337

infection. J Innate Immun, 2013; 5: 163-173.

10）Niyonsaba F, Madera L, Afacan N, Okumura

K, Ogawa H, Hancock RE: The innate

defense regulator peptides IDR-HH2, IDR-

1002, and IDR-1018 modulate human neutro-

phil functions. J Leukoc Biol, 2013; 94:

159-170.

11）Hara M, Yokoyama H, Fukuyama K, Kita-

mura N, Shimokawa N, Maeda K, Kanada S,

Ito T, Usui Y, Ogawa H, Okumura K,

Nishiyama M, Nishiyama C: Transcriptional

regulation of the mouse CD11c promoter by

AP-1 complex with JunD and Fra2 in den-

dritic cells. Mol Immunol, 2013; 53: 295-301.

12）Noguchi H, Miyata K, Sugita T, Hiruma M

(Midori), Hiruma M (Masataro): Treatment

of onychomycosis using a 1064nm Nd: YAG

laser. Med Mycol J, 2013; 54: 333-339.

13）Oka A, Mabuchi T, Ikeda S, Terui T, Haida Y,

Ozawa A, Yatsu K, Kulski JK, Inoko H: IL12B

and IL23R gene SNPs in Japanese psoriasis.

Immunogenetics, 2013; 65: 823-828.

14）Haida Y, Ikeda S, Takagi A, Komiyama E,

Mabuchi T, Ozawa A, Kulski JK, Inoko H,

Oka A: Association analysis of the HLA-C

gene in Japanese alopecia areata. Immunoge-

netics, 2013; 65: 553-557.

15）Nakayama H, Ogawa H, Takamori K, Iwa-

buchi K: GSL-enriched membrane microdo-

mains in innate immune responses. Arch

Immunol Ther Exp (Warsz), 2013; 61: 217-

228.

16）Nozawa K, Fujishiro M, Kawasaki M, Yama-

guchi A, Ikeda K, Morimoto S, Iwabuchi K,

Yanagida M, Ichinose S, Morioka M, Ogawa

H, Takamori K, Takasaki Y, Sekigawa I:

Inhibition of connective tissue growth factor

ameliorates disease in a murine model of

rheumatoid arthritis. Arthritis Rheum, 2013;

65: 1477-1486.

17）Aoki R, Kawamura T, Goshima F, Ogawa Y,

Nakae S, Nakao A, Moriishi K, Nishiyama Y,

Shimada S: Mast cells play a key role in host

defense against herpes simplex virus infec-

tion through TNF-α and IL-6 production. J

Invest Dermatol, 2013; 133: 2170-2179.

Department of General Medicine

<Original Articles>

＊ 1）Oike M, Yokokawa H, Fukuda H, Haniu T,

Oka F, Hisaoka T, Isonuma H: Association

between abdominal fat distribution and

atherosclerotic changes in the carotid artery.

Obes Res Clin Pract, Epub 2013 Oct 1.

2）Aung MN, Yuasa M, Lorga T, Moolphate S,

Fukuda H, Kitajima T, Yokokawa H, Mine-

matsu K, Tanimura S, Hiratsuka Y, Ono K,

Naunboonruang P, Thinuan P, Kawai S, Suya

Y, Chumvicharana S, Marui E: Evidence-

based new service package vs. routine

service package for smoking cessation to

prevent high risk patients from cardiovascu-

lar diseases (CVD): study protocol for ran-

domized controlled trial. Trials, 2013; 14: 419.

＊ 3）Shiga T, Yokokawa H, Taneda Y, Sugihara E,

Meijyo M, Mitsuhashi K, Hisaoka T, Isonuma

H: Age-specific effectiveness and safety of

newly initiated insulin therapy in Japanese

patients with uncontrolled diabetes. Diabetes

Ther, 2013; 4: 473-486.

4）Boku S, Naito T, Murai K, Tanei M, Inui A,

Nisimura H, Isonuma H, Takahashi H, Kiku-

chi K: Near point-of-care administration by

the attending physician of the rapid influenza

antigen detection immunochromatography

test and the fully automated respiratory virus

nucleic acid test: contribution to patient

management. Diagn Microbiol Infect Dis,

2013; 76: 445-449.

5）Oka F, Naito T, Oike M, Saita M, Inui A,

Uehara Y, Mitsuhashi K, Isonuma H, Hisaoka

T, Shimbo T: Influence of smoking on HIV

infection among HIV-infected Japanese men.

J Infect Chemother, 2013; 19: 542-544.

6）Sakurai T, Watanabe Y, Inui A, Oshima H,

Isonuma H, Dambara T, Naito T: A case of

human fascioliasis infected from eating water-

cress in Japan. J Gen Hosp Med, 2013; 5: 62-

66.

7）Naito T, Mizooka M, Mitsumoto F, Kanazawa

K, Torikai K, Ohno S, Morita H, Ukimura A,

Mishima N, Otsuka F, Ohyama Y, Nara N,

Murakami K, Mashiba K, Akazawa K, Yama-

moto K, Senda S, Yamanouchi M, Tazuma S,

Hayashi J: Diagnostic workup for fever of


338

unknown origin: a multicenter collaborative

retrospective study. BMJ Open, 2013; 3:

e003971.

8）Naito T: An initiative offering free pneumo-

coccal vaccination to victims of the Great East

Japan earthquake. Thorax, 2013; 68: 1068-

1069.

9）Yanagawa Y, Aihara K, Watanabe S, Take-

moto M, Naito T, Iba T, Tanaka H: Whole

body CT for a patient with sepsis. World

Academy of Science, Engineering and Tech-

nology, 2013; 7: 1789-1792.

10）Nishijima T, Takano M, Ishisaka M, Komatsu

H, Gatanaga H, Kikuchi Y, Endo T, Horiba M,

Kaneda S, Uchiumi H, Koibuchi T, Naito T,

Yoshida M, Tachikawa N, Ueda M, Yoko-

maku Y, Fujii T, Higasa S, Takada K,

Yamamoto M, Matsushita S, Tateyama M,

Tanabe Y, Mitsuya H, Oka S; Epzicom-Tru-

vada study team: Abacavir/lamivudine ver-

sus tenofovir/emtricitabine with atazanavir/

ritonavir for treatment-naive Japanese

patients with HIV-1 infection: a randomized

multicenter trial. Intern Med, 2013; 52: 735-

744.

11）Nishijima T, Gatanaga H, Shimbo T, Komatsu

H, Endo T, Horiba M, Koga M, Naito T, Itoda

I, Tei M, Fujii T, Takada K, Yamamoto M,

Miyakawa T, Tanabe Y, Mitsuya H, Oka S;

SPARE study team: Switching tenofovir/

emtricitabine plus lopinavir/r to raltegravir

plus darunavir/r in patients with suppressed

viral load did not result in improvement of

renal function but could sustain viral suppres-

sion: a randomized multicenter trial. PLoS

One, 2013; 8: e73639.

12）Haruyama Y, Fukuda H, Arai T, Muto T:

Change in lifestyle through health promotion

program without face-to-face intervention in

a large-scale Japanese enterprise. J Occup

Health, 2013; 55: 74-83.

＊13）Fujibayashi K, Fukuda H, Yokokawa H,

Haniu T, Oka F, Ooike M, Gunji T, Sasabe N,

Okumura M, Iijima K, Hisaoka T, Isonuma H:

Associations between healthy lifestyle behav-

iors and proteinuria and the estimated glo-

merular filtration rate (eGFR). J Atheroscler

Thromb, 2012; 19: 932-940.

＊14）Takahashi H, Friedmacher F, Fujiwara N,

Hofmann A, Kutasy B, Gosemann JH, Puri P:

Pulmonary FGF-18 gene expression is down-

regulated during the canalicular-saccular

stages in nitrofen-induced hypoplastic lungs.

Pediatr Surg Int, 2013; 29: 1199-1203.

15）Friedmacher F, Gosemann JH, Takahashi H,

Corcionivoschi N, Puri P: Decreased pulmo-

nary c-Cbl expression and tyrosine phos-

phorylation in the nitrofen-induced rat model

of congenital diaphragmatic hernia. Pediatr

Surg Int, 2013; 29: 19-24.

16）Friedmacher F, Gosemann JH, Fujiwara N,

Takahashi H, Hofmann A, Puri P: Expression

of Sproutys and SPREDs is decreased during

lung branching morphogenesis in nitrofen-

induced pulmonary hypoplasia. Pediatr Surg

Int, 2013; 29: 1193-1198.

17）Kishii K, Kikuchi K, Matsuda N, Yoshida A,

Okuzumi K, Uetera Y, Yasuhara H, Moriya K:

Evaluation of matrix-assisted laser desorp-

tion ionization-time of flight mass spectrome-

try for species identification of Acinetobacter

strains isolated from blood cultures. Clin

Microbiol Infect, 2013; 20: 424-430.

18）Yumura W, Kobayashi S, Suka M, Hayashi T,

Ito S, Nagafuchi H, Yamada H, Ozaki S:

Assessment of the Birmingham vasculitis

activity score in patients with MPO-ANCA-

associated vasculitis: sub-analysis from a

study by the Japanese Study Group for

MPO-ANCA-associated vasculitis. Mod

Rheumatol, 2013 May 28 [Epub ahead of

print].

19）Yamanishi Y, Ito-Ihara T, Nagao T, Uno K,

Kobayashi S, Muso E, Shane PY, Firestein GS,

Hashimoto H, Okazaki T, Suzuki K: Clinical

features of patients with anti-neutrophil

cytoplasmic autoantibodies targeting native

myeloperoxidase antigen. Mod Rheumatol,

2013; 23: 963-971.

20）Muso E, Okuzaki D, Kobayashi S, Iwasaki Y,

Sakurai MA, Ito A, Nojima H: Ficolin-1 is

up-regulated in leukocytes and glomeruli

from microscopic polyangiitis patients. Auto-

immunity, 2013; 46: 513-524.

21）Kawasaki A, Inoue N, Ajimi C, Sada KE,

Kobayashi S, Yamada H, Furukawa H,

Sumida T, Tohma S, Miyasaka N, Matsuo S,

Ozaki S, Hashimoto H, Makino H, Harigai M,


339

Tsuchiya N: Association of IRF5 polymor-

phism with MPO-ANCA-positive vasculitis

in a Japanese population. Genes Immun, 2013;

14: 527-529.

22）Kawakami T, Okudaira A, Okano T, Take-

uchi S, Kimura S, Soma Y, Ishizu A, Arimura

Y, Kobayashi S, Ozaki S: Treatment for

cutaneous arteritis patients with mononeuri-

tis multiplex and elevated C-reactive protein.

J Dermatol, 2013; 40: 955-961.

23）Matsuda J, Kaburaki T, Kobayashi S, Numaga

J: Treatment of recurrent anterior uveitis

with infliximab in patient with ankylosing

spondylitis. Jpn J Ophthalmol, 2013; 57: 104-

107.

24）Nagao T, Kusunoki R, Iwamura C, Kobayashi

S, Yumura W, Kameoka Y, Nakayama T,

Suzuki K: Correlation of interleukin-6 and

monocyte chemotactic protein-1 concentra-

tions with crescent formation and myeloper-

oxidase-specific anti-neutrophil cytoplasmic

antibody titer in SCG/Kj mice by treatment

with anti-interleukin-6 receptor antibody or

mizoribine. Microbiol Immunol, 2013; 57: 640-

650.

＊25）坂本梨乃，内藤俊夫，岡芙久子，齋田瑞恵，

乾啓洋，上原由紀，三橋和則，礒沼弘：非

専門医におけるHIV抗体スクリーニング検査

の実態．日病総合診療医会誌，2013；4：33-39．

<Reviews>

1）Kobayashi S, Fujimoto S: Epidemiology of vas-

culitides: differences between Japan, Europe

and North America. Clin Exp Nephrol, 2013;

17: 611-614.

Department of Clinical Pharmacology

<Original Articles>

1）Kamide K, Asayama K, Katsuya T, Ohkubo

T, Hirose T, Inoue R, Metoki H, Kikuya M,

Obara T, Hanada H, Thijs L, Kuznetsova T,

Noguchi Y, Sugimoto K, Ohishi M, Morimoto

S, Nakahashi T, Takiuchi S, Ishimitsu T,

Tsuchihashi T, Soma M, Higaki J, Matsuura

H, Shinagawa T, Sasaguri T, Miki T, Takeda

K, Shimamoto K, Ueno M, Hosomi N, Kato J,

Komai N, Kojima S, Sase K, Miyata T,

Tomoike H, Kawano Y, Ogihara T, Rakugi H,

Staessen JA, Imai Y; GEANE study group;

HOMED-BP study group: Genome-wide

response to antihypertensive medication

using home blood pressure measurements: a

pilot study nested within the HOMED-BP

study. Pharmacogenomics, 2013; 14: 1709-

1721.

Department of Sports Medicine

<Original Articles>

1）Wakamatsu K, Sakuraba K, Tsuchiya Y, Yama-

sawa F, Ochi E: Bone metabolism markers in

collegiate female runners. International Sport-

Med Journal, 2013; 14: 148-154.

2）Yaginuma S, Sakuraba K, Kadoya H, Koibuchi

E, Matsukawa T, Ito H, Yokoyama K, Suzuki

Y: Early bedtime associated with the salu-

tary breakfast intake in Japanese nursery

school children. International Medical Jour-

nal, 2013, in press

3）Kaneko M, Sakuraba K: Association between

femoral anteversion and lower extremity

posture upon single-leg landing: implications

for anterior cruciate ligament injury. J Phys

Ther Sci, 2013; 25: 1213-1217.

4）Miura T, Sakuraba K: Influence of different

spinal alignments in sitting on trunk muscle

activity. J Phys Ther Sci, 2013; 25: 483-487.

5）Tsuchiya Y, Ochi E, Sakuraba K, Kikuchi N,

Hwang I: Isokinetic strength and anaerobic/

intermittent capacity of Japanese lacrosse

players. Isokinet Exerc Sci, 2013; 21: 77-82.

6）Nakaniida A, Sakuraba K, Hurwitz E: Pedi-

atric orthopedic injuries requiring hospi-

talization; epidemiology and economics. J

Orthop Trauma, 2013; 28: 167-172.

7）Koikawa N, Aoki, E, Suzuki Y, Sakuraba S,

Nagaoka I, Aoki K, Shimmura Y, Sawaki K:

Wheat gluten hydrolysate affects race per-

formance in the triathlon. Biomed Rep, 2013;

1: 646-650.

Department of Epidemiology and Environmental

Health

<Original Articles>

＊ 1）Watanabe K, Iwahara C, Nakayama H, Iwa-

buchi K, Matsukawa T, Yokoyama K, Yama-

guchi K, Kamiyama Y, Inada E: Sevoflurane

suppresses tumour necrosis factor-α-induced

inflammatory responses in small airway epi-

thelial cells after anoxia/reoxygenation. Br J


340

Anaesth, 2013; 110: 637-645.

2）Vigeh M, Yokoyama K, Ohtani K, Shahbazi F,

Matsukawa T: Increase in blood manganese

induces gestational hypertension during

pregnancy. Hypertens Pregnancy, 2013; 32:

214-224.

3）Tamakoshi A, Ozasa K, Fujino Y, Suzuki K,

Sakata K, Mori M, Kikuchi S, Iso H; JACC

Study Group, Sakauchi F, Motohashi Y, Tsuji

I, Nakamura Y, Mikami H, Kurosawa M,

Hoshiyama Y, Tanabe N, Tamakoshi K,

Wakai K, Tokudome S, Hashimoto S, Wada Y,

Kawamura T, Watanabe Y, Miki T, Date C,

Kurozawa Y, Yoshimura T, Shibata A,

Okamoto N, Shio H: Cohort profile of the

Japan Collaborative Cohort Study at final

follow-up. J Epidemiol, 2013; 23: 227-232.

4）Suzuki Y, Hashiura Y, Sakai T, Yamamoto T,

Matsukawa T, Shinohara A, Furuta N: Sele-

nium metabolism and excretion in mice after

injection of (82) Se-enriched selenomethio-

nine. Metallomics, 2013; 5: 445-452.

＊ 5）Sugiyama K, Sada KE, Kurosawa M, Wada J,

Makino H: Current status of the treatment of

microscopic polyangiitis and granulomatosis

with polyangiitis in Japan. Clin Exp Nephrol,

2013; 17: 51-58.

＊ 6）Matsumoto M, Yamaguchi M, Yoshida Y,

Senuma M, Takashima H, Kawamura T, Kato

H, Takahashi M, Hirata-Koizumi M, Ono A,

Yokoyama K, Hirose A: An antioxidant,

N,Nʼ-diphenyl-p-phenylenediamine (DPPD),

affects labor and delivery in rats: A 28-day

repeated dose test and reproduction/develop-

mental toxicity test. Food Chem Toxicol, 2013;

56: 290-296.

7）Maruyama K, Iso H, Date C, Kikuchi S,

Watanabe Y, Wada Y, Inaba Y, Tamakoshi A:

Dietary patterns and risk of cardiovascular

deaths among middle-aged Japanese: JACC

Study. Nutr Metab Cardiovas Dis, 2013; 23:

519-527.

8）Lin Y, Yagyu K, Ueda J, Kurosawa M, Tama-

koshi A, Kikuchi S: Active and passive smoking

and risk of death from pancreatic cancer:

findings from the Japan Collaborative Cohort

Study. Pancreatology, 2013; 13: 279-284.

9）Lin Y, Ueda J, Yagyu K, Kurosawa M, Tama-

koshi A, Kikuchi S: A prospective cohort

study of shift work and the risk of death from

pancreatic cancer in Japanese men. Cancer

Causes Control, 2013; 24: 1357-1361.

10）Kurosawa M, Takagi A, Tamakoshi A, Kawa-

mura T, Inaba Y, Yokoyama K, Kitajima Y,

Aoyama Y, Iwatsuki K, Ikeda S: Epidemiology

and clinical characteristics of bullous congeni-

tal ichthyosiform erythroderma (keratinolytic

ichthyosis) in Japan: results from a nation-

wide survey. J Am Acad Dermatol, 2013; 68:

278-283.

11）Kuroda M, Kawakubo Y, Kuwabara H, Yoko-

yama K, Kano Y, Kamio Y: A cognitive-

behavioral intervention for emotion regulation

in adults with high-functioning autism spec-

trum disorders: study protocol for a random-

ized controlled trial. Trials, 2013; 14: 231.

12）Itoh H, Kitamura F, Yokoyama K: Estimates

of annual medical costs of work-related low

back pain in Japan. Ind Health, 2013; 51:

524-529.

13）Dewi N, Yanagie H, Zhu H, Demachi K, Shino-

hara A, Yokoyama K, Sekino M, Sakurai Y,

Morishita Y, Iyomoto N, Nagasaki T, Hori-

guchi Y, Nagasaki Y, Nakajima J, Ono M,

Kakimi K, Takahashi H: Tumor growth

suppression by gadolinium-neutron capture

therapy using gadolinium-entrapped lipo-

some as gadolinium delivery agent. Biomed

Pharmacother, 2013; 67: 451-457.

14）Iijima S, Yokoyama K, Kitamura F, Fukuda T,

Inaba R: Cost-benefit analysis of comprehen-

sive mental health prevention programs in

Japanese workplaces: a pilot study. Ind

Health, 2013; 51: 627-633.

＊15）Hagi N, Takamura M, Yokoyama K: Factors

affecting early psychiatric intervention for

patients with first-episode psychosis in Japan.

Early Interv Psychiatry, 2013; 7: 255-260.

16）Guo P, Yokoyama K, Pian F, Sakai K, Khalequz-

zaman M, Kamijima M, Nakajima T, Kitamura

F: Sick building syndrome by indoor air

pollution in Dalian, China. Int J Environ Res

Public Health, 2013; 10: 1489-1504.

<Reviews>

1）Yokoyama K, Iijima S, Ito H, Kan M: The

socio-economic impact of occupational dis-

eases and injuries (Editorial). Ind Health,

2013; 51: 459-461.


341

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Authors are requested to follow these instructions carefully. Manuscripts not preparedaccordingly will not be accepted.

General1. Juntendo Medical Journal is the official

journal of the Juntendo Medical Society,and aims to introduce achievements in thefields of basic and clinical medicine.Articles contributed are classified into thefollowing categories: original articles, re-views, lecture notes, and case reports.The articles must be written in English. Itis the authorsʼ responsibility to have theirmanuscripts checked by a native speaker,and a certificate of the check should bepresented when the manuscript is sub-mitted.Authors should respect the privacy ofpatients and their families. Identifyingdetails should be omitted if they are notessential, but patient data should never bealtered or falsified in an attempt to attainanonymity. Complete anonymity is diffi-cult to achieve, and informed consentshould be obtained if there is any doubt.

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Submissions should be original and unique;all submissions to the Juntendo MedicalJournal will be subjected to an automatedcomputer search (CrossCheck) for reusedor plagiarized materials carried out byCrossref.org.Authors (collaborating authors included)must sign and submit a form attestingthat the submitted experimental resultsare unpublished and not under considera-

342

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manuscript indicated below, which has been submitted to the Juntendo Medical

Journal.

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3．

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5．

6．

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8．

9．

10．

Declaration of Copyright Transfer

The content of this article manuscript, which has been submitted to the

Juntendo Medical Journal has not been published elsewhere in part or in full in

any academic journal, nor will it be submitted for publication elsewhere in the

future. The author(s) agrees that, effective upon acceptance for publication,

copyright of the article is transferred to the Juntendo Medical Society, although

all responsibility for its content rests with the author(s).

Title of the article

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347

Editorʼs Note

This issue features farewell lectures given by 5 retiring professors as special reviews, presenting

future perspectives on antibiotics, new biomarkers for chronic kidney disease, the history, current

status, and future of rehabilitation at Juntendo University, and 40-year outcomes of research on

mosquito ovarian development. I am moved by the originality of these activities, and confident that

their findings will also provide insights into medical practice and studies.

Minimally invasive surgery represents the marked changes which have taken place in treatment

methods over the past years. In this issue, endovascular repair is discussed in 4 papers. They

present the newest treatment methods that are minimally invasive but maximally effective in

multiple fields, including radiology, neurosurgery, and cardiovascular surgery. Although I am

engaged in a different field, these methods inspire me to use them for some procedures. Readers

will also be impressed by them.

Furthermore, the activities of each research group specializing in neurology, cellular and

molecular pharmacology, gastroenterology, respiratory medicine, metabolism and endocrinology,

nephrology, obstetrics and gynecology, and hematology are reported, which are informative.

In the training seminar held by Professor Shiina to master radiofrequency ablation for the

treatment of hepatic cancer, 18 participated from throughout Japan. Based on a well-developed

program, actual cases of live surgery were presented during it. The useful contents of this program

are carefully explained in this article so as to be sufficiently understandable even for those without

expertise.

For orthopedists, an original paper, entitled: Diversity of Arterial Branches in the Crural and

Foot Region as Correlated with the Relative Thickness of the Fibular and Posterior Tibial Arteries,

may be very useful, providing valuable findings on surgical procedures and contributing to the

further progress of clinical anatomy.

The Juntendo Medical Journal provides readers with a good opportunity to obtain new

knowledge and novel findings, as well as learn the latest research trends in- and outside their areas

of expertise. Since June 2014, all articles are now being published in English and as a result, the

readership of the journal has been steadily increasing. Charming illustrations by the artist Akiko

Miyamichi, characterizing it, are also worth seeing.

Kazuo Kaneko

Department of Orthopedics andMotor Organ

Call for feature article proposals

To introduce the latest medical findings, Juntendo Medical Journal features a specific focus area

for each issue. We would like to request all our readers to address any suggestions or proposals for

suitable focus areas to our editorial office.

348

順天堂醫事雑誌JUNTENDO MEDICAL JOURNAL

第61巻第3号（通刊896）平成27年（2015年）6月30日発行

明治8年（1875年）創刊

発行人順天堂医学会

編集発行責任者長岡功〒113-8421 東京都文京区本郷2-1-1順天堂大学内

順天堂医学会事務局：電話 03-5802-1586

E-mail [email protected]

編集・印刷：株式会社真興社代表者福田真太郎

〒150-0033 東京都渋谷区猿楽町19-2順天堂醫事雑誌編集室：電話 03-3462-1182

E-mail [email protected]

Ⓒ The Juntendo Medical Society 2015 Tokyo Japan20150630

今回は5名の退職教授のReviewsを拝見し，それぞれの先生方がご自分の仕事の集大成について紹介し

て頂き，改めてそのoriginalityに感嘆しております．Special Reviewsに取り上げられた論文として将来の

抗生剤の姿，慢性腎不全におけるバイオマーカー，順天堂大学におけるリハビリテーションの過去・現在・

未来，また41年間のクロニクル，蚊の卵巣に関する40年間の研究成果など感慨無量であり，読者の方々に

も診療や研究のヒントになると思います．

さて近年大きく変化した治療法として低侵襲手術がありますが，血管内治療について４件の論文があげ

られています．放射線科，脳神経外科，心臓血管外科など多くの領域で最小侵襲にして最大の効果を上げ

る最新の治療が紹介されております．私は全く異なる分野ですが，参考にさせて頂き何らかの治療に応用

したいと感じましたが，読者の方々はいかがでしょうか．

さらに，各教室の紹介が掲載されております．神経内科，基礎薬理学，消化器内科，呼吸器内科，代謝・

内分泌学，腎臓内科，産科・婦人科，血液内科です．是非ごらん頂きたいと存じます．

椎名教授による肝癌ラジオ波焼灼療法のセミナー報告には全国から18名の参加者があり，充実したプロ

グラムのもと実際のライブ症例も供覧されており，門外漢としても十分にわかりやすく説明されています

ので参考になる内容です．

整形外科医としては原著として掲載された腓骨・後脛骨動脈の下腿・足部での破格については外科的処

置を行う際に大変有用な検討であり，臨床解剖をさらに進めて行く示唆に富んだ論文であります．

自己の専門あるいは専門外においても新たな知識や未知の報告や現在の研究動向について知る良い機会

であると思います．

2014年6月から完全英文化したこの順天堂醫事雑誌が多くの読者の方々の支持を受ける内容になったと

考えます．またイラストレーションを担当して頂いている宮道明子さんの挿し絵もこの雑誌の特徴であ

り，一見の価値がある作品と存じます．

金子和夫

整形外科学講座

特集の企画募集

「順天堂醫事雑誌」では，医学界の最新知識を紹介するために，特集として総説を毎号に掲載しています．

読者の皆様には，特集として相応しい企画等がございましたら，編集室宛にご提案下さいますようお

願い申し上げます．

編集委員

委員長長岡功

（50音順）

射場敏明初田真知子

落合匠平澤恵理

加藤俊介三井田孝

金子和夫美田敏宏

桑鶴良平三宅幸子

小西清貴村上晶

小林弘幸横山和仁

高橋和久 Robert F Whittier

長岡正範宮道明子(イラスト)

編集後記

June 2015

The Juntendo Medical Society2－1－1 Hongo Bunkyo-ku, Tokyo, 113－8421 JAPAN

Tel：+81－3－5802－1586　E-mail：[email protected]

Juntendo Medical Journal

The Cutting Edge of Intravascular Treatment/Farewell Lectures of Retiring ProfessorJune 2015

The Juntendo M

edical Society


Juntendo Medical Journal　Vol. 61　No. 3　p. 216－348 Tokyo 2015. 6 61－3（896th issue）

ISSN　2187－9737　CODEN：JIZUA2 61（3）216―348（2015）

613

－

Foundedin 1875

What’s New from Juntendo University, TokyoJuntendo University Radiofrequency Ablation Training Program Shuichiro Shiina, et al.

Health Topics for Tokyoites: The Cutting Edge of Intravascular TreatmentDevelopment of Intra-Arterial Chemoembolization for Various Types of Cancer in Humans 　 Ryohei Kuwatsuru, et al.Development of Endovascular Therapy for Intracranial Aneurysms Hidenori OishiEndovascular Treatment for Ischemic Stroke Munetaka Yamamoto, et al.Endovascular Treatment of Gastrointestinal Bleeding Akihiko Shiraishi

Special Reviews: Farewell Lectures of Retiring ProfessorFuture Chemotherapy Preventing Emergence of Multi-Antibiotic Resistance 　 Keiichi Hiramatsu, et al.New Biomarkers for Diagnosis in Patients with Chronic Kidney Disease (CKD) Yasuhiko TominoRehabilitation in Juntendo University: Past, Present and Future Masanori NagaokaA Personal Research Chronicle for 41 Years at Juntendo University Takashi UenoA Retrospective of My 40 Years of Research on Mosquito Ovarian Development; 　Amino Acids, Not Solely an Element of Yolk Protein Synthesis, 　But an Activating Factor of Oogenesis Keikichi Uchida

Original ArticlesUsefulness of BCSH Criteria for Diagnosing Japanese Polycythemia Vera 　―Comparative Analysis with WHO 2008 Criteria― Yuriko Yahata, et al.Diversity of Arterial Branches in the Crural and Foot Region as Correlated with 　the Relative Thickness of the Fibular and Posterior Tibial Arteries Shiki Machida, et al.

Case ReportsAzuki Bean Allergy in a Japanese Child: a Case Report Kiyotaka Ohtani, et al.

Lecture NotesFunctional MRI Research on Memory Consolidation and Memory Retrieval Circuit Seiki Konishi

Medical EssaysSearching for the Greatest Treasure Jean Hino

Juntendo Research ProfilesDepartment of Neurology, Department of Gastroenterology, Department of Cellular and Molecular

Pharmacology, Department of Respiratory Medicine, Department of Metabolism and Endocrinology, Division of Nephrology, Department of Internal Medicine, Department of Obstetrics and Gynecology, Department of Hematology

Publication ListPublications from Juntendo University Graduate School of Medicine, 2013 [1/6]

Documents

順天堂醫 事雑誌...June 2015 The Juntendo Medical Society 2－1－1 Hongo Bunkyo-ku, Tokyo, 113－8421 JAPAN Tel：+81－3－5802－1586 E-mail：[email protected] Juntendo

順天堂醫事雑誌...June 2015 The Juntendo Medical Society 2－1－1 Hongo Bunkyo-ku, Tokyo, 113－8421 JAPAN Tel：+81－3－5802－1586 E-mail：[email protected] Juntendo