Recurrent Male Breast Cancer Accompanied by Carcinomatous Pleuritis That Responded to Combination Therapy with High-Dose Toremifene and Docetaxel

BACKGROUND: Male breast cancer (MBC) is a rare disease with no standard treatment compared to female breast cancer. There are very few reports that go beyond second-line chemotherapy and endocrine therapy for advanced and recurrent MBC. CASE REPORT: This report presents a case of recurrent MBC accompanied by carcinomatous pleuritis that responded to combination therapy with high-dose toremifene (TOR) and docetaxel (DOC). A 63-year-old male patient had previously undergone a modified radical mastectomy for left breast cancer and received several series of systemic chemotherapy and endocrine therapy. He complained of severe dyspnea, and was admitted to our hospital due to a massive left pleural effusion caused by carcinomatous pleuritis. He received combination therapy with high-dose TOR and biweekly DOC. The pleural effusion disappeared without any severe side effects after 4 cycles of the therapy. Thereafter, his disease stabilized for 1 year without re-increase of tumor markers under continuous treatment with the combination therapy. CONCLUSIONS: High-dose TOR and DOC might be effective even beyond second-line chemotherapy and endocrine therapy for MBC to overcome potential multiple drug resistance and diminish inevitable side effects.

A case of pulmonary oedema induced by suffocation

A 57-year old female civilian was suffocated by an intruder The victim (experienced severe dyspnoea) but violently resisted the assault. Two hours after this event, on admission to a Trauma Centre, she demonstrated left facial swelling with low percutaneous oxygen saturation. Chest X-ray and computed tomography demonstrated pulmonary oedema. This improved dramatically within a short time and she was discharged on the 5th hospital day. Pulmonary oedema induced by suffocation has been reported only rarely. The possible mechanisms by which pulmonary oedema might form after the relief of airway obstruction are discussed.

Outcomes of total pelvic exenteration for colorectal cancer

BACKGROUND/AIMS

Pelvic recurrence occurs in 4-33% of patients who have undergone a curative resection of primary rectal cancer and is thus a serious problem. However, the best treatment for primary rectal cancer remains unclear. In the present study was assessed the outcomes of total pelvic exenteration for colorectal cancer retrospectively.

METHODOLOGY

In the present study was investigated the medical charts of 25 patients who underwent total pelvic exenteration for primary colorectal cancer (n = 12) or postoperative local recurrence of colorectal cancer (n = 13) at the Department of Surgery (Division of Digestive Surgery) of the Kyoto Prefectural University of Medicine between the years 1997-2005.

RESULTS

The mean disease-free time interval between the first operation for primary colorectal cancer and total pelvic exenteration for the recurrence was 919 days (range, 203-3460 days). Total pelvic exenteration required a mean operation time of 940 minutes (range, 540-1395 minutes). The mean carcinoembryonic antigen (CEA) value was 25.5 ng/ml (range, 1-171.8 ng/ml). Five-year survival was achieved in 9 patients (36%) and inhospital death occurred in 3 patients (12%). The patients with curative resection survived significantly longer than the patients with non-curative resection.

CONCLUSIONS

When curative resection is achieved, total pelvic exenteration for colorectal cancer can result in long-term survival.

Histologic and electrophysiological study of nerve regeneration using a polyglycolic acid-collagen nerve conduit filled with collagen sponge in canine model

OBJECTIVES

To determine the rate of achieving electrophysiologically proved functional recovery by autonomic nerve regeneration, with the aid of an artificial nerve conduit.

METHODS

A polyglycolic acid (PGA) collagen nerve conduit filled with collagen sponge was interposed in a 10-mm-long gap of the right hypogastric nerve (HGN) in 16 dogs. Histologic evaluation of nerve regeneration and electrophysiological analysis at 2 weeks and 2, 3, 4, 5, 6, 7, and 8 months (n = 2, each) after surgery was performed, measuring the responses for the spermatic ducts (SD), bladder neck (BN), and prostate contraction, by stimulating the right lumbar splanchnic nerves (LSNs) from L2 to L4, after transection of the left HGN to eliminate substitutive pathways.

RESULTS

Two months after implantation, the regenerated neurofilaments were successfully extended through the graft from the proximal-to-distal direction. In 2 control dogs, electrostimulation of the right LSNs induced elevation of the intraluminal pressure of the SD, elevation of the BN pressure, and prostate contraction. No responses were observed in all dogs up to 6 months of follow-up after implantation. In 1 dog with a 7-month follow-up, electrostimulation elicited elevation of BN pressure alone. In both dogs with an 8-month follow-up, electrostimulation induced similar responses to control in all SD, BN, and prostate; however, after excision of the area of the interposed right HGN, no response was observed.

CONCLUSIONS

These results proved that regeneration of a 10-mm gap of the HGN, using a novel PGA-collagen nerve conduit could be achieved within 8 months.

Regeneration of peritoneum using amniotic membrane to prevent postoperative adhesions

BACKGROUND/AIMS

Adhesions following intraperitoneal surgery are frequent causes of small bowel obstruction. Attempts to prevent postoperative adhesions have mostly proven disappointing clinically. Currently used by ophthalmologists in ocular surface disorders, amniotic membrane transplantation can reduce inflammation and promote re-epithelization. We used amniotic membrane for facilitating peritoneal regeneration and prevention of adhesions with surgical trauma.

METHODOLOGY

20 rats were randomized in equal number into treatment or control groups. Seven days after operation, the incidence and severity of adhesions were evaluated. Histologic and immunohistochemical analyses were examined at 1, 4, 10 weeks after operation.

RESULTS

While severe adhesions were observed after 1 week between the cecum and surrounding organs in the control group, adhesion formation was significantly reduced in the amniotic membrane group. Histologic examination demonstrated that free-floating myofibroblasts in the peritoneal cavity attached to surfaces of amniotic membrane grafts to form a layered structure. Free-floating mesothelial cells were incorporated into the regenerating mesothelium on the myofibroblast layer in 4 weeks, while implanted amniotic membrane grafts were absorbed by 10 weeks. In the amniotic membrane group the cecum appeared nearly normal.

CONCLUSIONS

Amniotic membrane grafts reduced intraperitoneal adhesions after surgical trauma, were well absorbed, and served as a substrate for regenerating mesothelium.

Laparoscope-assisted superlow anterior resection combined with inter sphincteric rectal dissection for very low advanced rectal cancers combined with preoperative chemotherapy

Transanal intersphincteric resection (ISR) has been increasingly used as a surgical treatment for extremely low rectal cancer. We hypothesized that high quality less invasive surgery could be achieved if ISR and laparoscopic surgery were combined. The patient was a 46-year-old male with advanced rectal cancer on the lower rectum adjacent to the dentate line. The patient refused abdomino-perineal resection (APR), so we performed laparoscope-assisted ISR after preoperative chemotherapy. Previous dissection of this patient facilitated the muscle layer-oriented curative dissection, and more importantly, made the subsequent laparoscopic rectal excision effortless. This patient showed favorable recovery including postoperative anal function with no complications or recurrent disease. This procedure is feasible and has favorable short-term results for the radical treatment of very low rectal disease, while preserving anal function. This operative procedure may be appropriate for locally advanced rectal cancers to avoid a permanent colostomy.

Intrathoracic esophageal replacement by in situ tissue-engineered esophagus

OBJECTIVE

This study aimed to evaluate in situ tissue-engineered esophagus in a canine model after experimental resection and replacement of a full circumferential defect of the intrathoracic esophagus.

METHODS

Two types of scaffolding were fabricated. In the KF(+) group (n = 6), oral keratinocytes and fibroblasts cultured on human amniotic membrane were sheeted on polyglycolic acid felt with smooth muscle tissue and were then rolled around tubes. In the KF(-) group (n = 6), the same procedure was followed, but the keratinocytes and fibroblasts were omitted. Both scaffolds were wrapped in omentum and implanted in the abdomen. In the KF(+) group, at 3 weeks after implantation, the scaffold developed into a tube with a well-differentiated lumen of stratified squamous cells surrounded by a thick smooth muscle-like tissue (in situ tissue-engineered esophagus). A part of the esophagus was resected and replaced by the graft in the same dogs.

RESULTS

In the KF(-) group, strictures developed after esophageal replacement, with almost complete obstruction within 2 to 3 weeks. In contrast, in the KF(+) group, the in situ tissue-engineered esophagus showed good distensibility and the dogs remained without feeding problems through 420 days. Esophageal peristalsis transferred food to the stomach, despite the absence of peristaltic activity in the in situ tissue-engineered esophagus itself. The thickness of the squamous epithelial layer and the smooth muscle layer of the in situ tissue-engineered esophagus were similar to that of the adjacent native esophagus.

CONCLUSION

The in situ tissue-engineered esophagus can successfully replace the intrathoracic esophagus, and this procedure may offer a promising surgical approach to esophageal diseases.

Efficacy of prophylactic extended lymphadenectomy with gastrectomy for patients with node-negative advanced gastric carcinoma

BACKGROUND/AIMS

Extended lymphadenectomy with gastrectomy is widely performed for patients with advanced gastric carcinoma. However, the therapeutic value of prophylactic extensive lymphadenectomy in patients with node-negative advanced gastric cancer is controversial.

METHODOLOGY

We retrospectively analyzed 221 patients who underwent curative gastrectomy for advanced gastric carcinoma without lymph node metastasis to evaluate the effect of prophylactic extended lymphadenectomy on postoperative survival. The postoperative survival rate of patients who underwent extended lymphadenectomy was compared with that of patients who underwent limited lymphadenectomy. Predictive risk factors for tumor recurrence and recurrent patterns also were analyzed.

RESULTS

Extended lymphadenectomy improved the postoperative survival rate of patients with advanced tumors even when lymph node spread was absent. Whether or not prophylactic extended lymphadenectomy was performed significantly affected tumor recurrence in patients with node-negative advanced gastric carcinoma.

CONCLUSIONS

Extensive lymphadenectomy with gastrectomy prolongs survival of patients with node-negative advanced tumors.

Overexpression of RegIV in peritoneal dissemination of gastric cancer and its potential as A novel marker for the detection of peritoneal micrometastasis

BACKGROUND

Regenerating gene type IV (RegIV) is a candidate marker for cancer and inflammatory bowel disease. In this study, its potential as a novel marker for the detection of gastric cancer peritoneal micrometastases was examined.

PATIENTS AND METHODS

RegIV mRNA levels in the peritoneal washes of 95 gastric cancer patients and 22 with benign disease were quantified by real-time RT-PCR. To examine whether expression of RegIV enhance tumorigenicity or not, thirty two mice were injected intraperitoneally or subcutaneously with RegIV transfectants of TMK-1 cells, parental TMK-1 cells, or neomycin control transfectants.

RESULTS

RegIV expression was markedly higher in patients with peritoneal metastases compared to those without. The level of RegIV mRNA in gastric cancer patients was related to the extent of wall penetration. A cut-off value for RegIV-positive expression was based on an analysis of negative control patients with benign disease, and gastric cancer patients above the cut-off value constituted the micrometastasis (MM+) group. Based on this criteria, 3 out of 43 T1 or T2 cases were MM+ (93% specificity). Among 15 patients with peritoneal dissemination (7 out of 15 cases were positive by cytology), 14 cases were positive for RegIV expression (93% sensitivity), while analysis of carcinoembryonic antigen (CEA) mRNA failed to detect micrometastases in 4 cases (73% sensitivity). Combined analysis of CEA and RegIV improved the accuracy of diagnosis to 100%. The prognosis of RegIV-positive cases was significantly worse than that of RegIV-negative cases. Multivariate analysis using the Cox proportional hazards model suggested that RegIV may be an independent prognostic factor. Stable expression of RegIV significantly enhanced peritoneal metastasis in an animal model of gastric cancer.

CONCLUSION

These findings suggest that RegIV mRNA expression has the potential to serve as a novel marker for detecting peritoneal dissemination in gastric cancer.

[Quantification of circulating plasma DNA fragments as tumor markers in patients with esophageal and gastric cancer]

The quantity and quality of circulating DNA fragments was analyzed by quantitative real-time polymerase chain reactions (qPCR) in plasma from patients with esophageal and gastric cancer, in order to assess their diagnostic value. Plasma was collected preoperatively from 24 patients with esophageal cancer 53 patients with gastric cancer and from 21 healthy controls. qPCR was performed using two primer sets for the BETA-actin gene, amplifying short (102 bp) and long (253 bp) segments. The DNA concentrations in both the short and long segment assays of both cancer patients were significantly higher than the controls. The difference of concentrations between disease group and controls was more significant in esophageal cancer patients. The area under the receiver-operating characteristic curve was 0.83 (short) and 0.91 (long) for esophageal cancer patients, and 0.75 (short) and 0.67 (long) for gastric cancer versus the controls. There was also a significant difference in DNA integrity (short/long) between esophageal cancer patients and the control group (p = 0.001). qPCR assays for plasma DNA concentrations and their integrity can serve as new diagnostic markers for screening and monitoring patients with esophageal and gastric cancer.

[Long-term results of peritonectomy on the patients with peritoneal carcinomatosis]

Peritonectomy was done for 125 patients with peritoneal carcinomatosis (PC): 19-pseudomyxomaperitonei (PMP), 15-appendiceal carcinoma (AC), 20-colorectal cancer, 67-gastric cancer, 2-small bowel cancer and 2-peritoneal mesothelioma. Cytoreduction by the standard techniques was done in 130 patients with PC. Complete cytoreduction (CC-0) was achieved in 85 of 125 (68%) patients, who have undergone peritonectomy, but was performed only in 28 of 130 (21%) by the standard surgical techniques. CC-0 could be done to patients with peritoneal cancer indices (PCI) of less than 14. A Cox model showed that significant prognostic factors are CC-0, and the patients were younger than 66 years old. Accordingly, peritonectomy increased the incidence of CC-0, and may have improved the prognosis of patients with PC. Peritonectomy is recommended for patients with PMP, AC and colorectal cancer. In gastric cancer, it is indicated for patients with PCI less than 14.

[Successful treatment of huge peritoneal metastasis from duodenal gastrointestinal stromal tumor resistant for imatinib mesylate]

Constitutive activation of KIT receptor tyrosine kinase is a critical factor in the pathogenesis of gastrointestinal stromal tumors. Imatinib mesylate (IM, Glivec), a selective tyrosine kinase inhibitor, has been shown in clinical studies to work against such tumors. But there is little information on whether combination of IM and surgical treatment can prolong survival in cases with unresectable multiple liver metastases. We report a case of successful treatment of huge peritoneal metastasis from duodenal gastrointestinal stromal tumor resistant for IM. Therefore, we discuss some important implications. This 41-year-old Japanese man underwent a pancreaticoduodenectomy for GIST of the duodenum in January 2003. The postoperative course was good at first, but 3 months after the initial operation, MRI showed multiple liver metastases. The patient was treated with 400 mg of IM once daily with only weak liver dysfunction as a side effect. The initial response to treatment of CR continued for 20 months. Then huge mass of rt. abdomen appeared and gradually increased in size. Examination revealed that this mass is recurrent of peritoneal metastasis of the GIST. Extirpation was performed and this huge mass was recurrent GIST from omentum. Currently, IM is the first-line therapy for non-resectable GISTs, but a single agent therapy often leads to tumor resistance. IM-resistant GIST are treated with combination of novel molecular targeted-drug, RF, TAE, however, the effect is not enough. Surgical treatment is one of the successful treatments of huge peritoneal metastasis from duodenal gastrointestinal stromal tumor resistant for IM. Further examination in more cases of recurrent GIST is also necessary to estimate the effectiveness of treatment with IM.

Regeneration of skeletal muscle using in situ tissue engineering on an acellular collagen sponge scaffold in a rabbit model

Because of the limited ability of skeletal muscle to regenerate, resection of a large amount of muscle mass often results in incomplete recovery due to nonfunctional scar tissue. The aim of this study was to regenerate skeletal muscle using in situ tissue engineering in a rabbit model. In 18 male rabbits, a muscle defect (1.0 x ~1.0 x ~0.5 cm) was created in the vastus lateralis of both legs. A piece of cross-linked atelocollagen sponge was then inserted into the defect in one leg, whereas the defect in the other leg was left untreated. Both defects were finally covered with fascia. Twenty-four weeks after surgery, the defect that had been filled with the cross-linked atelocollagen sponge scaffold showed mild concavity and slight adhesion to the fascia, while the control side showed severe scar formation and shrinkage. Histologically, the regenerating myofibers at the site containing the collagen sponge were greater in number, diameter, and length than those at the control site. These results indicate that cross-linked atelocollagen sponge has the potential to act as a scaffold for muscle tissue regeneration.

Restoration of RUNX3 enhances transforming growth factor-beta-dependent p21 expression in a biliary tract cancer cell line

RUNX3 is a candidate tumor suppressor gene localized in 1p36, a region commonly inactivated by deletion and methylation in various human tumors. To elucidate the role of RUNX3 in transforming growth factor (TGF)-beta signaling in biliary tract cancer, we transfected Mz-ChA-2 cells, which do not express RUNX3 but have intact TGF-beta type II receptor and SMAD4 genes, with the RUNX3 expression plasmid pcDNA3.1/RUNX3 or with the vector pcDNA3.1 as a control. Four Mz-ChA-2/RUNX3 clones and one control clone were obtained. Although TGF-beta1 only slightly inhibited growth of the control cells, growth inhibition and TGF-beta-dependent G(1) arrest were significantly enhanced in the RUNX3-transfected clones. None of the clones, however, exhibited apoptosis. The slightly increased TGF-beta1-induced p21 expression in the control clone was strongly enhanced in the RUNX3-transfected clones, and was accompanied by augmented decreases in the expression of cyclins D1 and E. When RUNX3 small interfering RNA was added, TGF-beta-dependent induction of p21 was reduced in the RUNX3-transfected clones. Xenografts of the clones in nude mice demonstrated that tumorigenicity was significantly decreased in the RUNX3-transfected clones in inverse proportion to the expression levels of RUNX3. Based on these results, RUNX3 is involved in TGF-beta-induced expression of p21 and the resulting induction of TGF-beta-dependent G(1) arrest.

Rapid-prototyped temporal bone and inner-ear models replicated by adjusting computed tomography thresholds

Purpose:

This study aimed to investigate the validity of adjusting computed tomography thresholds in order to replicate a temporal bone model suitable for dissection training and education.

Materials and methods:

A simulated three-dimensional model of a human temporal bone was prototyped using selective laser sintering. The powder layers were laser-fused, based on detailed computed tomography data, and accumulated to create a three-dimensional structure. The computed tomography threshold value of the stapes was modified on standard triangular language file in order to replicate the stapes. The intensity value was determined to select the fluid lumen of the inner ear and the bone surface, in order to replicate the inner ear.

Results:

The model could be shaved, using surgical instruments, in the same manner as during real surgery. The stapes could be reproduced, making this model even more realistic than a previous version. The inner ear was recreated, along with the surrounding bony wall and the ossicles.

Conclusion:

This model facilitates dissection training and easy understanding of the relation between the labyrinth and the surrounding structures.

Frequent silencing of RUNX3 in esophageal squamous cell carcinomas is associated with radioresistance and poor prognosis

Radiotherapy is an effective treatment for some esophageal cancers, but the molecular mechanisms of radiosensitivity remain unknown. RUNX3, a novel tumor suppressor of gastric cancer, functions in transforming growth factor (TGF)-beta-dependent apoptosis. We obtained paired samples from 62 patients with advanced esophageal cancers diagnosed initially as T3 or T4 with image diagnosis; one sample was obtained from a biopsy before presurgical radiotherapy, and the other was resected in surgical specimens after radiotherapy. RUNX3 was repressed in 67.7% cases of the pretreatment biopsy samples and 96.7% cases of the irradiated, resected samples. The nuclear expression of RUNX3 was associated with radiosensitivity and a better prognosis than cytoplasmic or no RUNX3 expression (P<0.003); cytoplasmic RUNX3 expression was strictly associated with radioresistance. RUNX3 was downregulated and its promoter was hypermethylated in all radioresistant esophageal cancer cell lines examined. Stable transfection of esophageal cancer cells with RUNX3 slightly inhibited cell proliferation in vitro, enhanced the antiproliferative and apoptotic effects of TGF-beta and increased radiosensitivity in conjunction with Bim induction. In contrast, transfection of RUNX3-expressing cells with a RUNX3 antisense construct or a Bim-specific small interfering RNA induced radioresistance. Treatment with 5-aza-2'-deoxycytidine restored RUNX3 expression, increased radiosensitivity and induced Bim in both control and radioresistant cells. These results suggest that RUNX3 silencing promotes radioresistance in esophageal cancers. Examination of RUNX3 expression in pretreatment specimens may predict radiosensitivity, and induction of RUNX3 expression may increase tumor radiosensitivity.

Endocrine Cell and Nerve Regeneration in Autologous In Situ Tissue-Engineered Small Intestine

BACKGROUND

The purpose of this study was to regenerate a larger size of small intestinal tissue than that of our previous study and to evaluate the regeneration of the endocrine cells (ECC) and nerve system of autologous tissue-engineered small intestine. The effect of implantation of large numbers of smooth muscle cells (SMC) for the regeneration of small intestine was also investigated.

METHODS

Two types of scaffolds with different cell densities were fabricated: low density (LD) of SMC in the scaffold and high density (HD) of SMC in the scaffold. Both scaffolds were implanted into defects of isolated ileum in a canine model. Animals were sacrificed at 8, 12, 18, and 24 weeks.

RESULTS

The area of engineered small intestine in the HD group was four times larger than that in the LD group, although that was smaller in size than the original size of the defect. There were no significant changes in the thickness of regenerated smooth muscle layer (SML) in the LD and HD groups. The numbers of endocrine cells gradually increased after implantation. At 18 weeks of regeneration, the number of ECC reached levels comparable to that of normal mucosa. The nerve fibers extended to the center of the graft area and were observed in regenerated SML and regenerated villi at 24 weeks.

CONCLUSIONS

The ECC and nerve fibers were regenerated in autologous in situ tissue-engineered small intestine. Seeding a large number of SMC was not sufficient for the regeneration of the small intestine in a tubular configuration.

[Plasma methylation-specific polymerase chain reaction as a diagnostic tool for esophageal cancer patients]

This study was designed to perform methylation-specific polymerase chain reaction (MS-PCR) assay for p16, E-cadherin, and retinoic acid receptor beta genes on peripheral blood samples from patients with esophageal squamous cell cancers, and compare the results of MS PCR with conventional serum tumor markers and the CEA-specific reverse transcriptase polymerase chain reaction (RT-PCR) assay. Preoperative blood samples were obtained from 30 patients with esophageal cancer, and were subjected to MS PCR and RT-PCR assays. Eleven patients (37%) showed aberrant methylation of the promoter region of at least one gene. On the other hand, circulating tumor cells were detected in 11 patients (37%). There was no correlation between both results and conventional tumor markers. The MS-PCR and RT-PCR assays can serve as complementary diagnostic markers for screening and monitoring patients with esophageal cancers.

[An early detection of recurrence using reverse transcriptase-polymerase chain reaction (RT-PCR) and methylation-specific polymerase chain reaction (MSP) from peripheral blood in patients after gastrectomy]

Several molecular approaches, using peripheral blood of patients with cancers, have been assessed recently for ability to detect various primary and recurrent cancers at an early stage. One is the reverse transcriptase polymerase chain reaction (RT-PCR) analysis, which can detect a small number of circulating cancer cells. Another is the methylation-specific polymerase chain reaction (MSP), which detects tumor-specific alterations of cell-free serum DNA released from tumor into the circulation by necrosis and/or apoptosis. In the present study, we set out to assess the diagnostic value of the RT-PCR assay and the MSP assay for an early detection of recurrent diseases in patients after curative gastrectomy. Two of the 25 patients (8%) exhibited a CEA specific signal in their peripheral blood. On the other hand, seven patients (28%) showed aberrant methylation of the promoter region of at least one gene (3 patients for p16, 3 for E-cadherin, 3 for RARbeta genes, and 1 for CDH4 respectively). No abnormal signal was detected in sera from volunteers who served as controls. Of 10 patients who developed recurrences, a CEA-specific signal and aberrant methylation was demonstrated in plasma samples of 1 and 4 patients, respectively. One patient, without definite findings of recurrence at the time of analysis, developed recurrences 6 months later. Both assays can serve as markers that allow selection of those cases requiring more intensive screening and aggressive postoperative treatment.