Serum iron levels as a new biomarker in chemotherapy with leucovorin and fluorouracil plus oxaliplatin or leucovorin and fluorouracil plus irinotecan, with or without molecularly-targeted drugs

Serum iron levels have been reported to increase following the administration of various anticancer drugs. An increase in serum iron levels during therapy with leucovorin and fluorouracil plus oxaliplatin (FOLFOX) or leucovorin and fluorouracil plus irinotecan (FOLFIRI) was also observed. The aim of this study was to investigate the correlation between serum iron levels and prognosis in advanced colorectal cancer (CRC) patients treated with FOLFOX/FOLFIRI ± molecularly-targeted drugs. Serum iron levels were measured prior to and at 48 h after treatment with FOLFOX/FOLFIRI ± molecularly-targeted drugs in 72 advanced CRC patients, all of whom succumbed to the disease between December, 2005 and February, 2012. No patients received radiotherapy. Taking the median rate of increase in serum iron levels as the cut-off value in each therapy, the patients were divided into cohort I (increase rate greater than the cut-off value in at least one therapy) or cohort II (increase rate less than the cut-off value in all therapies). The χ² test and the t-test were used to compare patient characteristics between the two cohorts. Prognosis was evaluated between the two cohorts using the Kaplan-Meier method, the log-rank test and the Cox proportional hazards regression analysis. No significant bias in patient characteristics (including the frequency of chemotherapy or number of patients treated with molecularly-targeted drugs) was observed between the two cohorts. Serum iron levels were transiently elevated following treatment (P<0.001), returning to baseline within 2 weeks. Median survival time (MST) in cohort I (n=44) and cohort II (n=28) was 430 and 377 days, respectively. The MST was significantly higher in cohort I (P=0.0382). The multivariate analysis identified a small increase in serum iron levels as an independent risk factor for overall survival (OS). These results suggest that serum iron levels may be used as a new predictive factor in FOLFOX/FOLFIRI ± molecularly-targeted drug therapy. Serum iron levels may therefore prove to be a useful and convenient biomarker for OS in CRC patients.

Serum iron levels potential biomarker in FOLFOX/FOLFIRI with or without molecularly targeted drug therapy

e14651

Background: We reported an increase in serum iron levels during therapy with FOLFOX or FOLFIRI ± molecularly targeted drugs and a correlation between prognosis and transition of those levels in advanced colorectal cancer (CRC) patients (ASCO; 2009: #e15110, 2011: #e14141, 2012: #e14004). The aims of this prospective cohort study were to establish serum iron levels as a new biomarker in advanced CRC patients undergoing therapy based on this correlation and investigate the mechanism of this increase in serum iron levels. Methods: Eighty-one advanced CRC patients were treated; all died between Dec. 2005 and Nov. 2012; none received radiotherapy; 9 of these patients were undergoing treatment between Sep. 2012 and Nov. 2012. Serum iron levels were measured at before and 48 hr after treatment. Taking the median rate of increase in serum iron levels as the cut-off value in each therapy, the patients were categorized into cohort I (increase rate over cut-off value in at least one therapy) or cohort II (increase rate under cut-off value in all therapies). Prognosis was evaluated between the two. Hepcidin (Hepc), Interleukin-6 (IL-6) and soluble transferrin receptor (sTfR) were measured at before and 48 hr after treatment. Results: No significant bias in patient characteristics (including in frequency or type of regimen) was observed between the two cohorts. Serum iron levels transiently increased after treatment (p<0.001), then returning to baseline within 2 weeks. Median survival time (MST) in cohort I (n: 50) and cohort II (n: 31) was 437 and 378 days, respectively, with MST significantly better in cohort I (p=0.0417). Multivariate analysis identified Dukes’ stage, recurrence type, and serum iron level as independent risk factors for overall survival (OS). Hepc significantly increased after treatment (p<0.001), with no significant change in IL-6 or sTfR. Conclusions: Serum iron levels offer potential as an extremely useful and convenient biomarker for OS in CRC patients. While Hepc significantly increased, no significant decrease was observed in sTfR after treatment. This suggests that serum iron levels increased as a result of a treatment-induced reduction in iron consumption by bone marrow.

Evaluation of the individual 50% inhibitory area under the concentration curve of 5-fluorouracil based on the collagen gel droplet embedded culture drug sensitivity test in colorectal cancer

We have previously reported the 5-fluorouracil (5-FU) sensitivity of cancer cells from colorectal cancer (CRC) patients using the collagen gel droplet embedded culture-drug sensitivity test (CD-DST) under multiple drug concentrations and contact durations. Moreover, the area under the concentration curve (AUC) and growth inhibition rate (IR) were combined, resulting in the AUC-IR curve, which was approximated to the logarithmic curve. In the present study, we used the AUC-IR curve to calculate the individualized AUCIR50, the AUC value that imparts 50% growth inhibition. Individual AUCIR50 was calculated in CRC patients, and its distribution was evaluated. The cumulative distribution of individual AUCIR50 was regressed over two lines (logarithmic scale). Among the 45 resectable CRC patients, those who achieved more than the individual AUCIR50 during post-operative 5-FU-based chemotherapy demonstrated a trend towards better disease-free survival compared to those who did not achieve AUCIR50. Of the Dukes' D patients (n=10), those who achieved more than twice the individual AUCIR50 during post-operative 5-FU-based chemotherapy demonstrated significantly better survival rates (p=0.05) than those who did not. In this study, the distribution of the individual AUCIR50 suggested that approximately 6% of patients demonstrated very low 5-FU sensitivity. Therefore, the individual AUCIR50 was useful in classifying good, intermediate and poor 5-FU response. Achievement of the individual AUCIR50 may be a prerequisite for individualized 5-FU-based adjuvant chemotherapy. As well, the early achievement of twice the individual AUCIR50 may indicate an improved prognosis in Dukes' D patients. The individual AUCIR50 using CD-DST is useful in determining the individualized chemotherapy of CRC patients, thus CD-DST has the potential to facilitate the establishment of individualized chemotherapy for CRC.

Detailed features of palisade vessels as a marker of the esophageal mucosa revealed by magnifying endoscopy with narrow band imaging

The palisade vessels present at the distal end of the esophagus are considered to be a landmark of the esophagogastric junction and indispensable for diagnosis of columnar-lined esophagus on the basis of the Japanese criteria. Here we clarified the features of normal palisade vessels at the esophagogastric junction using magnifying endoscopy. We prospectively studied palisade vessels in 15 patients undergoing upper gastrointestinal endoscopy using a GIF-H260Z instrument (Olympus Medical Systems Co., Tokyo, Japan). All views of the palisade vessels were obtained at the maximum magnification power in the narrow band imaging mode. We divided the area in which palisade vessels were present into three sections: the area from the squamocolumnar junction (SCJ) to about 1 cm orad within the esophagus (Section 1); the area between sections 1 and 3 (Section 2); and the area from the upper limit of the palisade vessels to about 1 cm distal within the esophagus (Section 3). In each section, we analyzed the vessel density, caliber of the palisade vessels, and their branching pattern. The vessel density in Sections 1, 2, and 3 was 9.1 ± 2.1, 8.0 ± 2.6, and 3.3 ± 1.3 per high-power field (mean ± standard deviation [SD]), respectively, and the differences were significant between Sections 1 and 2 (P= 0.0086) and between Sections 2 and 3 (P < 0.0001). The palisade vessel caliber in Sections 1, 2, and 3 was 127.6 ± 52.4 µm, 149.6 ± 58.6 µm, and 199.5 ± 75.1 µm (mean ± SD), respectively, and the differences between Sections 1 and 2, and between Sections 2 and 3, were significant (P < 0.0001). With regard to branching form, the frequency of branching was highest in Section 1, and the 'normal Y' shape was observed more frequently than in Sections 2 and 3. Toward the oral side, the frequency of branching diminished, and the frequency of the 'upside down Y' shape increased. The differences in branching form were significant among the three sections (P < 0.0001). These results indicate that the density of palisade vessels is highest near the SCJ, and that towards their upper limit they gradually become more confluent and show an increase of thickness. Within a limited area near the SCJ, observations of branching form suggest that palisade vessels merge abruptly on the distal side. We have demonstrated that palisade vessels are a useful marker for endoscopic recognition of the lower esophagus.

Individualized chemotherapy for colorectal cancer based on the collagen gel droplet-embedded drug sensitivity test

The leucovorin (FOL) and fluorouracil (5-FU) plus oxaliplatin (l-OHP; FOLFOX) or FOL and 5-FU plus irinotecan (SN-38; FOLFIRI) regimens with or without molecularly-targeted drugs are widely used as first-line chemotherapy in the treatment of advanced colorectal cancer (CRC). Whether FOLFOX or FOLFIRI is administered first is not significant, however, it is essential that full administration of the targeted dosages of all 3 drugs, 5-FU, l-OHP and SN-38, is achieved. However, this is not always possible and second-line chemotherapy must be abandoned in certain cases. Where possible, the most effective regimen should be selected as the first line of treatment. The aim of this study was to determine whether first-line chemotherapy may be individualized using the collagen gel droplet-embedded drug sensitivity test (CD-DST). Specimens of primary tumors were obtained from 43 CRC patients who had received no preoperative chemotherapy. Informed consent to measure drug sensitivity was obtained from all patients. The CD-DST allows evaluation of drug sensitivity using isolated, 3-dimensionally cultured tumor cells in a small collagen gel droplet. The CD-DST was performed and the growth inhibition rate (IR) was obtained under incubation conditions (5-FU with l-OHP at 6.0 and 3.0 μg/ml, or 5-FU with SN-38 at 6.0 and 0.2 μg/ml, respectively, for 24 h). The cumulative distributions of the growth IRs under each condition were evaluated based on the evidence that the clinical response rates to FOLFOX and FOLFIRI were almost the same. Individualization of first-line treatment was possible in all patients, with FOLFOX and FOLFIRI showing higher efficacy in 26 and 15 patients, respectively, and equal efficacy in 2 cases. This method has the potential to facilitate the establishment of individualized first-line chemotherapy for CRC and improve the prognosis in such patients.

Serum iron levels as new predictive factor in FOLFOX/FOLFIRI with or without molecularly targeted drug therapy

e14004

Background: An increase in serum iron levels after administration of various anticancer drugs was reported (Follezou et al, NEOPLASMA 1985). We have also reported an increase in serum iron levels during FOLFOX and FOLFIRI therapies (ASCO 2009: #e15110) and a correlation between prognosis and transition of serum iron levels in advanced colorectal cancer (CRC) patients (ASCO 2011: #e14141). The aim of this cohort study was to evaluate the correlation between prognosis and serum iron levels in advanced CRC patients treated with FOLFOX/FOLFIRI ± molecularly targeted drugs. Methods: Serum iron levels were measured before and at 48 hr after treatment (FOLFOX/FOLFIRI ± molecularly targeted drugs) in 69 advanced CRC patients, all of whom died between December 2005 and December 2011. No patients were treated with radiotherapy. Taking the median rate of increase in serum iron levels as the cut-off value in each therapy, the patients were categorized into cohort I (increase rate over cut-off value in at least one therapy) and cohort II (increase rate under the cut-off value in all therapies). Prognosis was evaluated between the two cohorts using the Kaplan-Meier method and the log rank test. Results: No significant bias in patient characteristics was observed between the two cohorts. Serum iron levels transiently increased after treatment (p<0.001), then returning to baseline within 2 weeks. Median survival time (MST) in cohort I (n: 41) and cohort II (n: 28) was 430 and 377 days, respectively. The MST was significantly better in cohort I (p=0.0496). No significant differences were observed in the frequency of chemotherapies or number of patients treated with molecularly targeted drugs between the two cohorts. Conclusions: Cohort I showed a statistically significant better prognosis. The results suggest that serum iron levels could be used as a new predictive factor in FOLFOX/FOLFIRI ± molecularly targeted drug therapy. In Cohort II patients, molecularly targeted drugs should be used positively for further improvement in prognosis.

Overcoming memory T-cell responses for induction of delayed tolerance in nonhuman primates

The presence of alloreactive memory T cells is a major barrier for induction of tolerance in primates. In theory, delaying conditioning for tolerance induction until after organ transplantation could further decrease the efficacy of the regimen, since preexisting alloreactive memory T cells might be stimulated by the transplanted organ. Here, we show that such "delayed tolerance" can be induced in nonhuman primates through the mixed chimerism approach, if specific modifications to overcome/avoid donor-specific memory T-cell responses are provided. These modifications include adequate depletion of CD8+ memory T cells and timing of donor bone marrow administration to minimize levels of proinflammatory cytokines. Using this modified approach, mixed chimerism was induced successfully in 11 of 13 recipients of previously placed renal allografts and long-term survival without immunosuppression could be achieved in at least 6 of these 11 animals.

Novel diagnostic value of circulating miR-18a in plasma of patients with pancreatic cancer

BACKGROUND

Several recent studies have demonstrated that microRNAs (miRNAs) are stably detectable in the plasma/serum. We hypothesised that miR-18a in the plasma is a potential biomarker in patients with pancreatic cancer.

METHODS

miR-18a is located in the miR-17-92 cluster and reported to be highly expressed in pancreatic cancer tissues. This study was divided into three parts: (1) Confirmation of higher miR-18a levels in primary pancreatic cancer tissues and cell lines than in normal pancreatic tissues and a human fibroblast cell line. (2) Evaluation of the plasma miR-18a assay using quantitative RT-PCR by comparing plasma results obtained from 36 patients with pancreatic cancer and from 30 healthy volunteers. (3) Evaluation of the assay for monitoring tumour dynamics in patients with pancreatic cancer.

RESULTS

(1) The expression of miR-18a was significantly higher in pancreatic cancer tissues (P=0.012) and pancreatic cancer cell lines (P=0.015) than in normal tissues and fibroblasts. (2) Plasma concentrations of miR-18a were significantly higher in pancreatic cancer patients than in controls (P<0.0001). The value of the area under the receiver-operating characteristic curve (AUC) was 0.9369. (3) Plasma levels of miR-18a were significantly lower in postoperative samples than in preoperative samples (P=0.0077).

CONCLUSION

Circulating miR-18a might provide new complementary tumour markers for pancreatic cancer.

Randomized, controlled trial comparing UFT with S-1 as adjuvant therapy for curatively resected stage III colorectal cancer

515

Background: Oral anticancer drug, UFT, has recently been reported to improve both overall survival (OS) and relapse-free survival (RFS) for patients with stage III colorectal cancer in Japan. We conducted a randomized clinical trial to compare S-1 with UFT for adjuvant therapy in patients with stage III colorectal cancer.

Methods: Patients with stage III colorectal cancer (PS, 0 to 1; age, 20 to 80 years) were randomized to take either UFT (400mg/m2/day, 5days per week) or S-1 (80mg/m2/day, 28days per 6weeks) for 1 year started within 6 weeks following curative resection. The primary endpoint was to investigate relations of relapse-free survival (RFS) and tissue mRNA levels of 5-FU metabolism-related enzymes. The secondary endpoint was over all survival (OS) and safety.

Results: Between July 2005 and February 2008, a total of 100 patients were registered from 21 centers. There were no clear intergroup differences in background factors. When patients who relapsed within 1 year postoperatively were excluded, the percentages of patients who took expected dosage of medicine were 73% (30/41) and 72% (33/46) in UFT and S-1 groups, respectively. Grade 3 liver dysfunction (4%) or diarrhea (4%) occurred in UFT group, whereas grade3 to 4 myelosuppression (4%), diarrhea (4%), stomatitis (2%) were observed in S-1 group, but all of them were reversible. With a median follow-up period of 1,250 days, OS in patients of UFT and S-1 groups were 86.6% and 95.9%, respectively (p=0.06). The number of patients who relapsed in rectal cancer was significantly higher in UFT group (11/25) than in S-1 group (4/21, p<0.01). In a multivariate analysis, dihydropyrimidine dehydrogenase (DPD) mRNA level was shown as a factor of the recurrences. And S-1 improved RFS in patients with rectum cancer with high orotate phosphoribosil transferase (OPRT) mRNA level.

Conclusions: Oral anticancer drug, S-1, was no less effective than UFT as an adjuvant therapy for stage III colorectal cancer. Tissue levels of both DPD and OPRT mRNA were important parameters for postoperative prognosis in patients with stage III colorectal cancer who take oral 5-FU derivatives for adjuvant therapy.

No significant financial relationships to disclose.

Identification of responders/non-responders to 5-fluorouracil based on individual 50% inhibitory area under the concentration curve of 5-fluorouracil obtained with collagen gel droplet-embedded culture-drug sensitivity test in colorectal cancer

We previously reported the 5-fluorouracil (5-FU) sensitivity of cancer cells obtained from colorectal cancer (CRC) patients using the collagen gel droplet-embedded culture-drug sensitivity test (CD-DST). Multiple drug concentrations and contact durations, and the area under the concentration curve (AUC) and growth inhibition rate (IR) were combined, resulting in the AUC-IR curve, which was approximated to the logarithmic curve. Moreover, the individualized AUC(IR50), the AUC value which gives 50% growth inhibition, was calculated using the AUC-IR curve. This study aimed to identify responders/non-responders to 5-FU based on the individual AUC(IR50) obtained with CD-DST in order to establish individualized chemotherapy for CRC patients. The individual AUC(IR50) was calculated from each AUC-inhibition rate regression curve in all patients using the CD-DST. The cumulative distribution of the individual AUC(IR50) in CRC patients was evaluated. The cumulative distribution of the individual AUC(IR50) was regressed over the sigmoid curve (logarithmic scale). The approximate expression was almost exactly y=ab^exp(-cx) (a=0.9739, b=1.7096E-21, c=0.8990, the sum of square residuals, 0.0279). In the 80 cases examined, no notable change was observed in the regression curve when the number of patients increased. A standard curve was obtained describing responders to 5-FU among all CRC patients. From this standard curve, we ascertained that non-responders accounted for approximately 5% of all patients. Moreover, we were able to classify responders into good or intermediate responders to 5-FU. The standard curve describing response to 5-FU in CRC patients offers a useful tool in the establishment of individualized chemotherapy.

Prospective replacement of magnifying endoscopy by a newly developed endocytoscope, the 'GIF-Y0002'

Endocytoscopy has the potential to reduce the need for histologic examination of biopsy specimens in cases of esophageal squamous cell carcinoma. Up to now, two types of endocytoscope have been used: the probe type and the integrated type. In this study we examined the utility of a newly developed endocytoscope, the 'GIF-Y0002,' which has a single lens allowing consecutive magnification from the conventional endoscopy level up to ×380. Using the GIF-Y0002, we examined 24 examples of normal esophageal mucosa to clarify the appearance of the microvasculature of the normal squamous epithelium in vivo. We also examined 11 cases of esophageal cancer in the same way, employing methylene blue as a vital dye to stain the surface cells. In normal squamous epithelium, we clarified the relationship between the subepithelial capillary network, IPCLs and subepithelial venules. With methylene blue staining, we observed typical squamous cells (low nuclear density and low N/C ratio without nuclear abnormality). When cancerous lesions were observed using lower-power magnification, we were able to visualize their microvascular architecture to the same extent as when conventional magnifying endoscopy was used. Furthermore, at higher magnification, we were able to visualize the features of blood flow in both superficial and advanced cancer. Methylene blue staining revealed an increase of nuclear density in all cases of cancer. The pathologist agreed to omit biopsy histology in 81.8% (9/11) of cancer cases considering the nuclear density and nuclear abnormality. The GIF-Y0002 provides information on cell abnormality in addition to the features revealed by currently available magnifying endoscopy.

Evaluation of serum iron levels during FOLFOX4 and FOLFIRI therapies

FOLFOX4 and FOLFIRI are effective regimens for the treatment of advanced colorectal cancer, and their use together with molecular targeting drugs has recently become more common. In the present study, we evaluated the changes in the serum iron levels of patients undergoing FOLFOX4 or FOLFIRI therapy alone or in combination with bevacizumab (BV). The serum iron level was increased 48 h after therapy and was restored to baseline 2 weeks afterwards in colorectal cancer patients who received FOLFOX4 or FOLFIRI alone or in combination with BV. This transient increase in serum iron was observed repeatedly during chemotherapy. The serum iron level was 71.66±28.96 μg/dl (mean ± standard deviation) before treatment and significantly increased to 186.82±83.17 μg/dl (p<0.001) 48 h after therapy. A transient increase in serum iron levels was also observed when FOLFIRI was administered to a patient after tumor resection. In contrast, no decrease in blood hemoglobin, no increase in liver enzymes and no increase in urinary iron excretion were observed. Based on these results, it can be concluded that an increase in serum iron may be induced by a transient change in iron distribution within the body after FOLFOX4/FOLFIRI therapy with or without BV.

Indian hedgehog roles in post-natal TMJ development and organization

Indian hedgehog (Ihh) is essential for embryonic mandibular condylar growth and disc primordium formation. To determine whether it regulates those processes during post-natal life, we ablated Ihh in cartilage of neonatal mice and assessed the consequences on temporomandibular joint (TMJ) growth and organization over age. Ihh deficiency caused condylar disorganization and growth retardation and reduced polymorphic cell layer proliferation. Expression of Sox9, Runx2, and Osterix was low, as was that of collagen II, collagen I, and aggrecan, thus altering the fibrocartilaginous nature of the condyle. Though a disc formed, it exhibited morphological defects, partial fusion with the glenoid bone surface, reduced synovial cavity space, and, unexpectedly, higher lubricin expression. Analysis of the data shows, for the first time, that continuous Ihh action is required for completion of post-natal TMJ growth and organization. Lubricin overexpression in mutants may represent a compensatory response to sustain TMJ movement and function.

[Intrathecal baclofen therapy for spastic paraparesis due to aortic dissecting aneurysm; recent progress in treatment strategy]

A 48-year-old man suffered from acute dissection of thoracic aortic aneurysm which eventually led to replacement of the ascending aorta with a tube graft. During this clinical course, circulatory failure in intercostal artery resulted in spinal cord infarction followed by moto-sensory disturbance below Th7 dermatomic area. Seven months later, spasticity with pain in both lower extremities became conspicuous that was uncontrollable by any oral medication. Eventually the patient underwent the implantation of continuous infusion pump for intrathecal baclofen therapy (ITB). The clinical condition was remarkably improved and now has been well controlled. ITB, authorized by Japanese Ministry of Health Labour and Welfare in 2006, has notable therapeutic effects on spasticity derived from any sort of central nervous disorder. More promotive enlightenment if ITB is indispensable for enhancement of its medical benefit in Japan.

[A case of gastric cancer with peritoneal dissemination-efficacy of combination therapy with S-1 and docetaxel]

The efficiency of new anti-cancer drugs such as the S-1 system was demonstrated in a controlled study comparing treatment and non-treatment groups. We encountered a patient with gastric cancer demonstrating peritoneal dissemination, who was successfully treated by combination therapy using S-1 and docetaxel. A 62-year-old woman was admitted to the hospital due to appetite loss and nausea. Upper GI endoscopy demonstrated a type 3 gastric cancer extending from the upper to lower body of the stomach. In the pelvic cavity, an abdominal CT scan demonstrated massive ascites. An abnormally high CA72-4 (143.8 U/mL) level was detected in serum. Treatment with S-1 and docetaxel was started with the following regimen: daily oral administration of 80 mg/body S-1 for 14 days, followed by a 7-day rest and infusion of 40 mg/m2 docetaxel on day 1. After 4 courses, the sites of dissemination had disappeared, and the serum CA72-4 value returned to normal. The patient clinically achieved good QOL by this method, which was very effective for non-resected gastric cancer with peritoneal dissemination.

Roles of the primary cilium component Polaris in synchondrosis development

Primary cilia regulate several developmental processes and mediate hedgehog signaling. To study their roles in cranial base development, we created conditional mouse mutants deficient in Polaris, a critical primary cilium component, in cartilage. Mutant post-natal cranial bases were deformed, and their synchondrosis growth plates were disorganized. Expression of Indian hedgehog, Patched-1, collagen X, and MMP-13 was reduced and accompanied by decreases in endochondral bone. Interestingly, there was excessive intramembranous ossification along the perichondrium, accompanied by excessive Patched-1 expression, suggesting that Ihh distribution was wider and responsible for such excessive response. Indeed, expression of heparan sulfate proteoglycans (HS-PGs), normally involved in restricting hedgehog distribution, was barely detectable in mutant synchondroses. Analyses of the data provides further evidence for the essential roles of primary cilia and hedgehog signaling in cranial base development and chondrocyte maturation, and point to a close interdependence between cilia and HS-PGs to delimit targets of hedgehog action in synchondroses.

Evaluation of the distinction between responder and non-responder in FOLFOX/FOLFIRI based on the alteration of serum iron level

e15110

Background: The alteration of serum-iron level during chemotherapy is already reported (Follezou, NEOPLASMA 1985). However, the correlation to prognosis has not been evaluated. The aim of this study was to evaluate the correlation between prognosis and serum-iron level in advanced / metastatic colorectal cancer (aCRC / mCRC) patients treated by FOLFOX / FOLFIRI. Methods: Serum-iron levels, hemoglobin, AST and ALT serum levels in immediately pre and post chemotherapy were analyzed in 58 aCRC / mCRC patients received FOLFOX-4 / FOLFIRI therapy between April 2005 and September 2008. 26 patients received FOLFOX-4 / FOLFIRI therapy as the final chemotherapy died by the time of analysis. These patients were categorized into the high increase group and the low increase group using 200% increase as cut-off value and the prognosis was compared. Results: Mean serum-iron levels in immediately pre and post chemotherapy were 71.7±29.0μg/dl and 186.8±83.2μg/dl, respectively, and significant increase after chemotherapy was observed (p<0.001). This increase was transient and returns to pre chemotherapy level by the start of next course. This alteration was always observed on the chemotherapy. The median survival times from the initiation of FOLFOX-4 / FOLFIRI therapy for the high increase group (n: 5) and the low increase group (n: 21) were 487 and 182 days, respectively, and was significantly better in the high increase group (p=0.004). The alterations of hemoglobin, AST and ALT serum levels in immediately pre and post chemotherapy were not observed. Conclusions: It is suggested that serum-iron increase is a biological response not attributed to leakage from erythrocyte and hepatocyte. Significantly better prognosis in high serum-iron group may suggest the usefulness of serum-iron level to distinguish responder and non-responder in FOLFOX-4/FOLFIRI therapy.

No significant financial relationships to disclose.

Preemptive living donor liver transplantation in glycogen storage disease Ia: case report

Even with substantial progress in the management of patients with glycogen storage disease type Ia (GSD-Ia), hepatic and renal complications may still develop during long-term follow-up. Herein, we report a case of preemptive living donor liver transplantation in a patient with GSD-Ia.

PATIENT

The patient was a 5-year-old boy in whom GSD-Ia was diagnosed at age 10 months. Clinical symptoms included frequent hypoglycemic episodes, hyperlipidemia, hyperuricemia, and growth retardation, which were poorly controlled using conventional treatments. At age 5 years, frequent massive nasal bleeds developed, which led to severe anemia. The patient was brought to our institute for living donor liver transplantation (LDLT). Because GSD-Ia usually responds to dietary and medical treatments, we had a long discussion to determine whether preemptive LDLT was indicated. Transplantation was performed using the left lateral liver segment from the patients mother. The weight of his native liver was almost 2 kg. After reperfusion of the graft, the blood glucose concentration rapidly increased, and regular glucose was administered throughout the operation. The posttransplantation course was uneventful. The patient had no episodes of hypoglycemia with a regular diet. Total cholesterol, triglyceride, and uric acid concentrations also reverted to normal without medication. The patient had a few episodes of nasal bleeding after transplantation, which stopped spontaneously. He was discharged from our hospital with normal liver function.

CONCLUSION

Patients with GSD-Ia should be considered for preemptive LDLT to improve their quality of life when clinical symptoms do not respond to appropriate treatment.