[Association of obesity and other cardiovascular risk factors with stroke the Japan Arteriosclerosis Longitudinal Study--Existing Cohorts Combined (JALS-ECC)]

OBJECTIVES

To assess the relationship between metabolic risk factors and the incidence of stroke stratified by obesity, by conducting a meta-analysis using individual participant data from prospective cohort studies.

METHODS

A total of 19,173 individuals from 10 cohort studies participated at baseline after 1985. Metabolic risk factors were defined using the established criteria in Japan. Participants were subdivided into five categories according to the levels of risk factors and obesity defined by BMI > or = 25 (kg/m2). Multivariate adjusted hazard ratios (HRs) for the incidence of stroke and the population attributable risk (PAR) were estimated by Poisson regression.

RESULTS

During an average 7.1-year follow-up period, 374 stroke events occurred. Hypertension was highest among the risk factors not concerned with BMI stratification. The HR for stroke was 2.48 (95% CI: 1.75-3.5) for BMI < 25 with 1 other risk factor and 3.75 (2.58-5.45) with 2 or more, 2.38 while it was (1.58-3.59) for BMI > or = 25 with 0 or 1 factor and 3.26 (2.11-5.02) with 2 or more. The HR was significantly elevated in all categories with one or more risk factors. The PAR was highest in the category of BMI < 25 with 1 risk factor (23.3%) and second highest in the category of BMI < 25 with 2 or more. The respective PARs for BMI > or = 25 with 0 or 1 and 2 or more risk factors were 8.1% and 8.0%. Similar results were found from the analyses of different stroke subtypes.

CONCLUSION

The HR was found to be significantly elevated with the number of risk factors both with and without obesity. The attributable risk for stroke was larger in the non-obese group. Therefore, public health intervention based only on obesity may miss many of those at high risk of stroke so the focus should not only be on obesity but also cardiovascular risk factors.

Risk assessment chart for curability of early gastric cancer with endoscopic submucosal dissection

BACKGROUND

Endoscopic submucosal dissection (ESD) was introduced worldwide as a new treatment option for early gastric cancer, but curability prediction has not been evaluated on an individual basis.

OBJECTIVE

To analyze factors contributing to the curability of early gastric cancer after ESD and to construct a risk assessment chart for the probability of curability.

DESIGN

Single-institution retrospective review.

SETTING

University hospital.

PATIENTS

From June 2000 to April 2010, we treated 961 early gastric cancers in 784 patients (mean age 70.2 years).

INTERVENTION

ESD procedures were performed using typical sequences.

MAIN OUTCOME MEASUREMENTS

Risk factors related to resectability (en bloc or piecemeal resection) and curability (curative or noncurative resection) after ESD were analyzed using logistic regression analysis. Using this model, we constructed a risk assessment chart to predict the probability of noncurability from patient characteristics.

RESULTS

The en bloc and curative resection rates were 98.9% and 88.1%, respectively, after ESD. Significant contributors to noncurative ESD were large lesions, upper location, and ulcer findings. Predicted noncurability probabilities were displayed in 4 colors for each risk level (light blue, blue, yellow, and red) by combining tumor size, tumor location, and ulcer findings. Probability of noncurability was highest (≥ 40%) in ulcerative large tumors (>30 mm in diameter) in the upper location (red) and lowest in nonulcerative small tumors (≤ 20 mm in diameter) in the lower location (light blue).

LIMITATIONS

Retrospective design and single-site data collection.

CONCLUSIONS

This risk assessment chart shows individuals their pretreatment curability assessment with successful ESD and may be an educational tool for trainees or a decision-making tool.

Single-incision laparoscopic surgery using colon-lifting technique for colorectal cancer: a matched case-control comparison with standard multiport laparoscopic surgery in terms of short-term results and access instrument cost

BACKGROUND

Single-incision laparoscopic surgery (SILS) has been used for colorectal cancer as a minimally invasive procedure. However, there are still difficulties concerning effective triangulation and countertraction. The study's purpose was to clarify the usefulness of the colon-lifting technique (CLT) in SILS for colorectal cancer.

METHODS

SILS was performed for cancer (cT2N0 or less) of the right-sided colon (near the ileocecum), sigmoid, or rectosigmoid. The SILS™ Port was used for transumbilical access. A suture string was inserted through the abdominal wall and passed through the mesocolon. The colon was retracted anteriorly and fixed to the abdominal wall. The main mesenteric vessels were placed under tension. Lymph node dissection was performed by medial approach. Short-term surgical outcomes and access port costs were compared between SILS (using CLT) and the standard multiport technique (MPT). The two groups were case-matched by propensity scoring. Analyzed variables included preoperative Dukes stage and tumor location.

RESULTS

From June 2009 to April 2011, 27 patients underwent SILS, and from April 2005 to April 2011, 85 patients underwent MPT. Propensity scoring generated 23 matched patients per group for SILS versus MPT comparisons. There were no significant differences in operating time, blood loss, early complications, postoperative analgesic frequency, or length of hospital stay. One MPT patient was converted to open surgery (4.5%); no SILS patients were converted. There were no significant differences in the length of distal cut margin and the number of harvested lymph nodes, except incision length (SILS vs. MPT: 33 vs. 55 mm, P < 0.001). Significant differences favored SILS in access instrument cost (SILS vs. MPT: 62,761 vs. 77,130 Japanese yen, P < 0.001).

CONCLUSIONS

SILS performed using CLT was safe and effective in providing radical treatment of cT2N0 cancer in the right-sided colon, sigmoid, or rectosigmoid. SILS was advantageous with respect to cosmesis and lower cost of access instruments.

A comparison of multimodality treatment: two and four courses of neoadjuvant chemotherapy using S-1/CDDP or S-1/CDDP/docetaxel followed by surgery and S-1 adjuvant chemotherapy for macroscopically resectable serosa-positive gastric cancer: a randomized phase II trial (COMPASS-D trial)

This randomized Phase II trial will compare the outcome of neoadjuvant chemotherapy using two and four courses of S-1 plus cisplatin or S-1 plus cisplatin plus docetaxel by a two-by-two factorial design for patients with macroscopically resectable serosa-positive gastric cancer. After neoadjuvant chemotherapy, patients will receive D2 gastrectomy followed by S-1 chemotherapy for 1 year postoperatively. The primary endpoint is the 3-year overall survival. The sample size is 120 for the two hypotheses: the superiority of four courses compared with two courses and the superiority of S-1 plus cisplatin plus docetaxel compared with S-1 plus cisplatin. This trial will be able to define the more suitable number of cycles and better regimen of neoadjuvant chemotherapy for gastric cancer.

Surgical outcomes of laparoscopy-assisted gastrectomy versus open gastrectomy for gastric cancer: a case-control study

BACKGROUND

The aim of this study was to clarify the technical feasibility and oncological efficacy of laparoscopy-assisted gastrectomy (LAG) for gastric cancer compared with open gastrectomy (OG).

METHODS

Between April 2002 and March 2008, a series of 623 patients with gastric cancer underwent R0 gastrectomy (314 LAG patients and 309 OG patients). Age, gender, lymph node dissection, and pathological stage were matched by propensity scoring, and 212 patients (106 LAG and 106 OG) were selected for analysis after the exclusion of 40 patients who had proximal gastrectomy. Intraoperative factors, postoperative morbidity, long-term quality of life (QOL), and survival were evaluated. Moreover, these outcomes were also compared between the laparoscopy-assisted total gastrectomy (LATG) and the open total gastrectomy (OTG).

RESULTS

There was no significant difference in preoperative characteristics between the two patient groups. Regarding intraoperative characteristics, blood loss was significantly lower in the LAG group (143 ml) than in the OG group (288 ml), while operation time was significantly longer in the LAG group (273 min) than the OG group (231 min). The degree of lymph node dissection and number of retrieved lymph nodes did not differ between the two groups. There were no significant differences in postoperative courses or overall and disease-specific survival (89.8% vs. 83.6%, P = 0.0886; 100% vs. 95.2%, P = 0.1073) except time to first flatus and time to use of nonsteroidal anti-inflammatory derivatives between the two groups. Significantly fewer patients felt wound pain in the LAG group 1 year after surgery. Analyses between the LATG and OTG groups showed similar results.

CONCLUSIONS

LAG for gastric cancer may be both feasible and safe. However, it will be necessary to conduct a well-designed randomized controlled trial comparing short-term and long-term outcomes between LAG and OG in a larger number of patients.

Semaphorin 4D, a lymphocyte semaphorin, enhances tumor cell motility through binding its receptor, plexinB1, in pancreatic cancer

Pancreatic ductal adenocarcinoma (PDAC) is a highly malignant tumor, for which the development of new biomarkers and therapeutic targets has become critical. The main cause of poor prognosis in PDAC patients is the high invasive and metastatic potential of the cancer. In the present study, we report a new signaling pathway that was found to mediate the enhanced tumor cell motility in pancreatic cancer. Semaphorin 4D (Sema4D) is a ligand known to be expressed on different cell types, and has been reported to be involved in the regulation of immune functions, epithelial morphogenesis, and tumor growth and metastasis. In this study, we revealed for the first time that the cancer tissue cells expressing Sema4D in PDAC are tumor-infiltrating lymphocytes. The overexpression of Sema4D and of its receptor, plexinB1, was found to be significantly correlated with clinical factors, such as lymph node metastasis, distant metastasis, and poor prognosis in patients with PDAC. Through in vitro analysis, we demonstrated that Sema4D can potentiate the invasiveness of pancreatic cancer cells and we identified the downstream molecules. The binding of Sema4D to plexinB1 induced small GTPase Ras homolog gene family, member A activation and resulted in the phosphorylation of MAPK and Akt. In addition, in terms of potential therapeutic application, we clearly demonstrated that the enhanced-cell invasiveness induced by Sema4D could be inhibited by knockdown of plexinB1, suggesting that blockade of plexinB1 might diminish the invasive potential of pancreatic cancer cells. Our findings provide new insight into possible prognostic biomarkers and therapeutic targets in PDAC patients.

Novel Lens culinaris agglutinin-reactive fraction of α-fetoprotein: a biomarker of hepatocellular carcinoma recurrence in patients with low α-fetoprotein concentrations

BACKGROUND

Lens culinaris agglutinin-reactive fraction of α-fetoprotein (AFP-L3) is a specific marker used to detect hepatocellular carcinoma (HCC). However, its clinical utility is not sufficient in patients with low total AFP concentrations because of limitations in instrument sensitivity. Recent advances have led to the introduction of a highly sensitive AFP-L3% assay (sensitive AFP-L3%), provided by a novel on-chip, liquid-phase binding assay. This cross-sectional study was conducted to evaluate the clinical significance of the sensitive AFP-L3% in determining HCC recurrence in patients with low total AFP concentrations.

METHODS

A total of 370 consecutive patients with HCC were screened within 1-3 months of locoregional treatment, and 215 of the 370 patients showed serum AFP <20 ng/ml. Total AFP, sensitive AFP-L3%, and des-gamma-carboxy prothrombin (DCP) were measured in those 215 patients and HCC recurrence was evaluated by radiological findings. Optimal cutoff values of the markers for detecting HCC recurrence were obtained on the basis of receiver operating characteristic (ROC) curve.

RESULTS

The area under the ROC curve of the total AFP, sensitive AFP-L3%, and DCP in HCC patients with serum AFP <20 ng/ml were 0.638, 0.724, and 0.779, respectively. The diagnostic accuracies of the total AFP, sensitive AFP-L3%, and DCP were 60.9% (cutoff value 5 ng/ml), 67.7% (cutoff value 7%), and 64.6% (cutoff value 40 ng/ml), respectively.

CONCLUSIONS

The new sensitive AFP-L3% assay provides great utility in determining HCC recurrence in patients with low AFP concentrations. Further studies focusing on the combinatorial use of the markers (total AFP, sensitive AFP-L3%, and DCP) are required.

Investigation of the prevalence and number of aberrant crypt foci associated with human colorectal neoplasm

BACKGROUND

Aberrant crypt foci (ACF) are considered to be useful as surrogate biomarker for colorectal cancer (CRC), but the biological significance of ACF remains controversial. We attempted to investigate the relationship between the presence of ACF and human colorectal carcinogenesis using a relatively large sample size.

METHODS

We carried out high-magnification chromoscopic colonoscopy to identify ACFs in 861 subjects undergoing a diagnostic endoscopy at the Yokohama City University Hospital. The present study compared the prevalence and number of ACFs in three subject groups (normal subjects, adenoma cases, and CRC cases). The correlations between the demographic and behavioral characteristics of the subjects and the prevalence of ACFs were also assessed.

RESULTS

The prevalence of ACF was 64%, 88%, and 95%, and the mean number of ACF was 3.6, 6.2, and 10.1, in normal subjects, adenoma cases, and CRC cases, respectively. When differences in the prevalence and number of ACFs among age- and sex-stratified subject groups were examined, significant stepwise increments from normal subjects to adenoma cases to CRC cases were apparent (P < 0.001). Moreover, an age- and sex-adjusted multiple logistic regression analysis revealed that smoking and alcohol habits had a synergistic effect, increasing the prevalence of ACFs as well as the risk of CRC (P < 0.001).

CONCLUSIONS

These results suggested that ACF may serve as a reliable surrogate biomarker for human colorectal carcinogenesis.

IMPACT

The use of ACF as an endpoint may enable the size, duration, and cost of CRC chemoprevention studies to be reduced.

Clostridium difficile infection in patients with ulcerative colitis: investigations of risk factors and efficacy of antibiotics for steroid refractory patients

BACKGROUND AND OBJECTIVE

The incidence of Clostridium difficile infection (CDI) has increased throughout the world and patients with ulcerative colitis (UC) are at a high risk for CDI. Potentially, CDI can exacerbate UC. Therefore, knowledge on the prevalence of CDI should contribute to better management of UC patients.

METHODS

The presence of toxin A antigen was defined as CDI, and the outcome of the test in patients with active UC during 2006-2009 was reviewed for identifying patients with CDI. Demographic data (disease profile, clinical response to medications and the need for colectomy) in UC patients with CDI were compared with the data from CDI free UC patients.

RESULTS

Fifty-five of 137 patients (40.1%) were CDI positive. Univariate and multivariate analyses revealed that CDI was not associated with any demographic factor. Intensive antibiotic therapy spared five of 17 (29.4%) steroid refractory patients with CDI from steroids. CDI was not a predictor of colectomy although this could be an outcome of efficient eradication strategy.

CONCLUSION

CDI was not associated with any demographic factor or colectomy rate. However, CDI eradication therapy allowed some refractory patients to withdraw from steroids. Patients with active UC benefit from regular CDI test and eradication treatment for CDI.

Higher discontinuation and lower survival rates are likely in elderly Japanese patients with advanced hepatocellular carcinoma receiving sorafenib

AIM

  Sorafenib is approved for the treatment of advanced hepatocellular carcinoma (HCC) in Japan; however, its tolerability and efficacy in elderly patients with HCC have not been clarified. We aimed to evaluate the tolerability and efficacy of sorafenib with increasing age.

METHODS

  As part of a retrospective, multicenter cohort study conducted between May 2009 and February 2010, patients with advanced HCC received 400 mg sorafenib twice daily (standard dosage) or once daily (half-dosage) until disease progression or treatment intolerance.

RESULTS

  The mean age of the enrolled patients (n = 76) was 70.3 years, and 24 of them were ≥75 years old. The prognostic factors for survival were age < 75 years, performance status score zero, α-fetoprotein level < 1000 ng/mL, des-gamma-carboxy prothrombin level < 1000 ng/mL, and treatment duration ≥ 1 month. The median treatment duration and overall incidence of adverse drug reactions (ADRs) were not statistically different with increasing age. However, subgroup analysis revealed that treatment discontinuation because of ADRs was more frequent among the ≥75-year-old patients (41.7%) than among the <75-year-old ones (15.0%) with the standard dosage (P = 0.047); this trend was not observed among those who received the half-dose regimen.

CONCLUSIONS

  Sorafenib has modest efficacy and acceptable toxicity in younger (<75 years) patients with HCC; however, elderly patients experience some side effects when it is administered at the standard dosage.

Body Mass Index and Risk of Stroke and Myocardial Infarction in a Relatively Lean Population

Background–

The association of overweight/obesity with the incidence of cardiovascular diseases, especially stroke, has not been comprehensively examined in relatively lean populations in which stroke is more prevalent than coronary heart disease.

Methods and Results–

Pooled individual data from 16 Japanese cohorts comprising 45 235 participants ages 40 to 89 years without previous history of cardiovascular disease were studied. During follow-up, 1113 incident strokes and 190 myocardial infarctions were identified. At baseline, mean ages of men and women were 55.4 and 56.5 years and mean body mass indices (BMI) were 23.0 and 23.4 kg/m 2 , respectively. Compared with those with BMI <21.0, incidence rates of cerebral infarction in subjects with BMI ≥27.5 were significantly elevated in both men (hazard ratio, 1.81; 95% confidence interval [CI], 1.28 to 2.56) and women (hazard ratio, 1.65; 95% CI, 1.23 to 2.21), adjusted for age, smoking, and drinking habit. Incidence of cerebral hemorrhage was also associated positively with BMI in both men (hazard ratio, 2.51; 95% CI, 1.21 to 5.20) and women (hazard ratio, 1.98; 95% CI, 1.12 to 3.52). Adjustment for systolic blood pressure, a mediating factor, significantly attenuated most BMI association with stroke in both sexes. For myocardial infarction, the hazard ratio was 3.16 (95% CI, 1.66 to 6.01) for BMI 27.5 or greater versus less than 21.0 only in men, which appeared partly mediated by total cholesterol and SBP.

Conclusions–

Overweight/obesity was associated with an increased risk of cerebral infarction and hemorrhage in men and women and myocardial infarction in men. Weight control may have the potential to prevent both stroke and myocardial infarction in Japan.

A meta-analysis of (18)F-Fluoride positron emission tomography for assessment of metastatic bone tumor

PURPOSE

The aim of this study was to assess the diagnostic performance of (18)F-Fluoride positron emission tomography (PET) or positron emission tomography/computed tomography (PET/CT) compared with bone scintigraphy (BS) planar or BS planar and single photon emission computed tomography (SPECT) in evaluating patients with metastatic bone tumor.

MATERIALS AND METHODS

We performed a meta-analysis of all available studies addressing the diagnostic accuracy of (18)F-Fluoride PET, (18)F-Fluoride PET/CT, BS planar, and BS planar and SPECT for detecting the metastatic bone tumor. We determined sensitivities and specificities across studies, calculated positive and negative likelihood ratios, and drew summary receiver operating characteristic curves using hierarchical regression models. We also compared the effective dose and cost-effectiveness estimated by data from the enrolled studies between (18)F-Fluoride PET or PET/CT and BS planar or BS planar and SPECT.

RESULTS

When comparing all studies with data on (18)F-Fluoride PET or PET/CT, sensitivity and specificity were 96.2% [95% confidence interval (CI) 93.5-98.9%] and 98.5% (95% CI 97.0-100%), respectively, on a patient basis and 96.9% (95% CI 95.9-98.0%) and 98.0% (95% CI 97.1-98.9%), respectively, on a lesion basis. The Az values of (18)F-Fluoride PET or PET/CT were 0.986 for the patient basis and 0.905 for the lesion basis, whereas those of BS or BS and SPECT were 0.866 for the patient basis and 0.854 for the lesion basis. However, the estimated effective dose and average cost-effective ratio were poorer for (18)F-Fluoride PET or PET/CT than those of BS planar or BS planar and SPECT.

CONCLUSION

(18)F-Fluoride PET or PET/CT has excellent diagnostic performance for the detection of metastatic bone tumor, but the estimated effective dose and average cost-effective ratio are at a disadvantage compared with BS planar or BS planar and SPECT.

Effect of preoperative hyperfibrinogenemia on recurrence of colorectal cancer without a systemic inflammatory response

BACKGROUND

Disorders in the blood coagulation system are often associated with malignancy. Patients with colorectal cancer (CRC) have been shown to have abnormal data for various coagulation tests.

METHODS

We retrospectively analyzed the relation between the preoperative plasma fibrinogen level and tumor recurrence in 569 patients with CRC who underwent curative surgical resection and were followed up without adjuvant chemotherapy.

RESULTS

The plasma fibrinogen level showed a positive association with tumor recurrence, age, sex, T stage, and TNM classification. When divided with the median value, hyperfibrinogenemia is positively correlated with tumor recurrence, although it lost independence in the multivariate analysis. In the C-reactive protein (CRP)-negative population, hyperfibrinogenemia is independently correlated with tumor recurrence and recurrence-free survival. In contrast, hyperfibrinogenemia has no effect on recurrence in CRP-positive patients.

CONCLUSIONS

Hyperfibrinogenemia is clinically relevant in tumor recurrence before a systemic inflammatory response and thus can be a useful predictor of recurrence in the preinflammatory stage of CRC.

Four blood pressure indexes and the risk of stroke and myocardial infarction in Japanese men and women: a meta-analysis of 16 cohort studies

BACKGROUND

Information has been sparse on the comparison of 4 blood pressure (BP) indexes (systolic BP [SBP], diastolic BP, pulse pressure, and mean BP [MBP]) in relation to long-term incidence of stroke and myocardial infarction, particularly in middle-aged and older Asians.

METHODS AND RESULTS

The Japan Arteriosclerosis Longitudinal Study Group conducted a meta-analysis of 16 cohort studies in Japan. A total of 48,224 men and women 40 to 89 years of age participated at baseline, and 1231 stroke events and 220 myocardial infarction events occurred during an average 8.4-year follow-up. Multivariate-adjusted hazard ratios with a 1-SD higher value for each BP index were determined by Poisson regression. Analyses were also done in 4 age-sex groups. All 4 BP indexes were significantly related to all stroke risk. Stroke risk was most strongly related to MBP and SBP in both sexes and most weakly related to pulse pressure. Both stroke subtypes, ischemic and hemorrhagic, were most strongly related to MBP and SBP in both sexes. In addition, in men and women 70 to 89 years of age, MBP or SBP showed the strongest relation to all stroke risk. Myocardial infarction risk was most strongly related to SBP or MBP in both sexes. For any end points in any age-sex groups, pulse pressure was not the strongest predictor.

CONCLUSIONS

The long-term incident risk of stroke and myocardial infarction associated with high BP in East Asian populations should be assessed mainly on the basis of SBP. MBP also may be an important predictor, but pulse pressure is a less important predictor for cardiovascular disease risk.