Morphologic and histopathologic changes in the bowel after super-selective transcatheter embolization for focal lower gastrointestinal hemorrhage

Purpose: To evaluate the safety of superselective arterial embolization therapy in the lower gastrointestinal tract. The sequelae on normal enteric tissue in lower gastrointestinal arterial embolization were retrospectively reviewed.

Material and Methods: To control hemorrhage and tumor blood supply, 14 patients were treated by superselective transcatheter embolization at different levels of the colonic and small intestine vessels via the superior and inferior mesenteric arteries using microcoils and/or gelatin sponge. Normal enteric tissues in the embolized areas were analyzed for the occurrence of ischemic changes by clinical follow-up, colonoscopy, and surgery.

Results: Normal bowel function was preserved in 13 patients. In 1 patient treated with numerous gelatin sponge particles delivered from the proximal arcade of the superior mesenteric artery, significant muscular fibrosis occurred.

Conclusion: Superselective arterial embolization for lower gastrointestinal hemorrhage can be safely performed by minimizing the amount of embolic materials and delivering them as distally as possible.

[Excretion Management During Colorectal Cancer Chemotherapy]

There are almost no reports about drug excretion management during colorectal cancer chemotherapy. Anticancer chemotherapeutic drugs excreted in urine and feces may exert toxic effects and promote teratogenesis, mutagenesis, and carcinogenesis. To assess the knowledge of patients about drug excretion, a questionnaire survey was performed among 45 patients receiving chemotherapy for colorectal cancer in our hospital; among them, 36 patients completed the survey. Most of the patients did not know about the excretion and toxic effects of anticancer drugs. The results indicate that patients should be instructed on the management ofexcretion during chemotherapy to minimize toxic exposure. We believe that unnecessary exposure of patients and their families to anticancer drugs should be minimized. This study highlights the importance of issuing guidelines regarding excretion management during cancer chemotherapy.

Single-site laparoscopic right hemicolectomy for acute cecal volvulus: a case report

BACKGROUND

Cecal volvulus is an uncommon cause of acute abdomen in patients. Cecal volvulus is currently treated mostly with right hemicolectomy with laparotomy, which is an invasive surgical procedure. Less invasive techniques, such as endoscopic decompression, have a poor success rate.

CASE PRESENTATION

We report a case of cecal volvulus in a 35-year-old male patient. He was successfully treated with single-site laparoscopic decompression by inserting a catheter through the amputated appendix, detorsion, and hemicolectomy. This approach was less invasive than the traditional approach and resulted in satisfactory outcomes and cosmesis.

CONCLUSIONS

Application of single-site laparoscopic colectomy to acute cecal volvulus is feasible using decompression of the dilated colon by inserting a catheter through the amputated appendix. To the best of our knowledge, this is the first report of this treatment.

17β-Estradiol in the systemic circulation derives mainly from the parietal cells in cholestatic female rats

PURPOSE

Estrogenic symptoms of liver disease patients including biliary tract disorder with high frequency is observed in clinical cases. However, the origin of 17β-estradiol which is abundant enough to cause symptoms remains uncertain. In male rats, it has been reported that the parietal cells which have an abundance of aromatase-synthesized 17β-estradiol, and a part of 17β-estradiol secreted into the portal vein, may flow into the systemic circulation under a pathophysiological condition of the liver including bile duct ligation (BDL). The aim of this study is to reveal the origin of 17β-estradiol increment in female rats and to investigate the effect of BDL on the ovary during the estrus cycle.

METHODS

Wistar female rats were used, and the common bile duct was ligated twice and transected completely at 7 days before termination. Serum portal venous and arterial 17β-estradiol levels, Cyp19a1 expressions, aromatase protein levels, and estrogen receptor (ER) α levels in the liver were measured during the estrus cycle.

RESULTS

Both arterial and portal venous 17β-estradiol levels increased 2.9 times at proestrus and maintained constant levels during the cycle. The expression of Cyp19a1 and aromatase protein in the stomach maintained constant levels, and significantly decreased during the estrus cycle in the ovary. Hepatic ERα protein and Esr1 expressions decrease by BDL in all stages.

CONCLUSIONS

These results suggest that the increment of serum 17β-estradiol levels in obstructive cholestasis induced by BDL is derived from 17β-estradiol secreted from the parietal cells in females as well as males.

141 EXPRESSION STATUS OF AQUAPORINS 3, 7, AND 9 IN BOVINE PRE-IMPLANTATION EMBRYOS

The aquaporins (AQP) are a family of small integral membrane proteins that work as channels for rapid water transport. In mouse embryos, AQP3, AQP7, and AQP9 were found to play important roles in the pre-implantation development or adaptive cellular response to osmotic stress. In addition, because AQP3, AQP7, and AQP9 permeate not only water but also cryoprotectant, such as glycerol, these AQP thought to be involved in the process of cryopreservation. However, little information is available for AQP in bovine embryos. The understanding of the mechanisms mediated by AQP that embryos utilise to survive during culture and the process of cryopreservation will contribute to development of in vitro culture systems and cryopreservation procedures for bovine embryos. The aims of present study were to clarify the expression status of AQP3, AQP7, and AQP9 in bovine pre-implantation embryos, and to evaluate the expression level of AQP3 in in vivo-derived (IVD) and IVF bovine embryos. For production of IVF embryos, cumulus-oocyte complexes (COC) were aspirated from ovaries collected at a local slaughterhouse. The COC were in vitro matured, fertilized, and then cultured for 7 days. The IVD embryos at early blastocyst (EB) and blastocyst (BC) stage were obtained from donor cows treated with superovulation and AI. In experiment 1, in order to clarify the expression of AQP3, AQP7, and AQP9 mRNA in bovine pre-implantation embryos, total RNA was extracted from pools of 30 IVM oocytes, pools of 15 IVF embryos at 2- to 4-cell, 8- to 16-cell, compaction morula (CM), EB, BC, and expanded blastocyst (ExBC) stage, and RT-PCR was performed followed by agarose gel electrophoresis. In experiment 2, in order to clarify the expression status of AQP3, AQP7, and AQP9 during bovine pre-implantation development after zygotic gene activation, total RNA was extracted from pools of 15 IVF embryos at 8- to 16-cell, CM, EB, BC and ExBC stage (n = 5), and relative quantifications of AQP mRNA were performed using real-time RT-PCR. Data were analysed by Scheffé’s method. In experiment 3, AQP3 transcript levels in single IVD and IVF embryos at EB and BC stages (n = 10) was evaluated by real-time RT-PCR. Data were analysed by Mann-Whitney’s U test. In experiment 1, AQP3 and AQP7 transcripts were detected in IVM oocytes and all stages of embryos. AQP9 mRNA was detected in IVM oocytes and in 2- to 4-cell, 8- to 16 cell, CM, and EB stage embryos, but was not detected in BC and ExBC stage embryos. In experiment 2, AQP3 and AQP7 transcript levels were significantly increased from 8- to 16-cell to CM and EB stage, and significantly decreased from EB to BC and ExBC stages (P < 0.05). AQP9 transcript level was significantly decreased from 8- to 16-cell to CM and EB stage (P < 0.05). In experiment 3, AQP3 transcript level in IVF embryos was significantly lower than that in in vivo embryos at the BC stage (P < 0.05). Our results indicate that AQP3 and AQP7 may have specific roles at morula and EB stage in bovine embryos. In addition, AQP3 expression is influenced by developmental condition of bovine embryos.

[A Case of Recurrent Sigmoid Cancer after EMR Curatively Resected after Neoadjuvant Chemotherapy]

The Guidelines for Colorectal Cancer Treatment list indication and curative resection criteria for the endoscopic resection of mucosal and submucosal invasive colorectal cancers. Here, we report the case of a woman who underwent endoscopic mucosal resection (EMR) but should have undergone curative resection because the submucosal invasion depth in this case was 1,200 mm; however, she did not undergo additional curative surgery. Although liver and lymph node metastases were observed 7 years later, we were able to resect all of these tumors after neoadjuvant chemotherapy. We strongly recommend additional curative surgery for patients who fulfill the criteria for curative resection after EMR because of the very high recurrence rates in such cases.

[A Case of Consciousness Disturbance Caused by Hyperammonemia during a mFOLFOX6 Regimen for Metastatic Colon Cancer]

Systemic chemotherapy based on 5-fluorouracil (5-FU) is a standard treatment for unresectable or recurrent colorectal cancer. Although hyperammonemia is known as one of the adverse side effects of 5-FU, a disturbance of consciousness caused by hyperammonemia is not a usual finding. We encountered a case of 5-FU-related consciousness disturbance with respiratory depression. A woman in her sixties was diagnosed with metastatic cecum cancer, involving peritoneal dissemination and hydronephrosis due to retroperitoneal invasion. After resection of the primary lesion, systemic chemotherapy, including capecitabine, irinotecan, bevacizumab and cetuximab, was administered for the metastatic lesions. As a third-line of treatment, the mFOLFOX6 plus bevacizumab regimen was administered. On the second day of the first course, the patient complained of nausea and vomiting. On third day, her consciousness level was deteriorating. The level of ammonia in the blood was abnormally high. Therefore, we diagnosed consciousness disturbance caused by hyperammonemia resulting from high-dose 5-FU infusion. The symptom improved immediately after mechanical ventilation and intravenous infusion. Renal dysfunction is considered a risk factor for hyperammonemia caused by 5-FU, and it is necessary to pay particular attention in patients with renal dysfunction who receive chemotherapy with 5-FU.

[A Case of Neuroendocrine Carcinoma of the Gallbladder]

A 58-year-old woman presented to our hospital with a huge hepatic mass. A CT scan showed an enhanced mass lesion on the fundus of the gallbladder and an enhanced mass ring on the gallbladder bed. Since FDG-PET showed no evidence of metastasis, we performed cholecystectomy, hepatectomy of S4a/5, and regional lymph node dissection. The immunohistochemical study of the specimen was positive for CK7, CK20, chromogranin A, and synaptophysin. The Ki-67 labeling index was 50%, and the SSTR2 score was 2+. The patient was diagnosed with neuroendocrine carcinoma. Since she was in poor condition and on hemodialysis, we started administration of somatostatin analog at the time of recurrence, and soon her diarrhea improved but the tumor increased in size.

[A Case of Inoperable Advanced Gastric Cancer with Gastric Outlet Obstruction in Which Oral Intake Could Be Prolonged by Duodenal Stenting]

INTRODUCTION

The indications for duodenal stent placement for gastric outlet obstruction caused by gastric cancers remain controversial. We report the case of a patient with inoperable advanced gastric cancer with gastric outlet obstruction in whom oral intake could be prolonged for more than 2 years by duodenal stenting. A 60-year-old man diagnosed as having cStage Ⅳ gastric cancer with liver, peritoneum, and lymph node metastases underwent duodenal stent placement before first-line chemotherapy. After 8 months, the duodenal stent was found to be dislocated in the horizontal part of the duodenum due to tumor shrinkage. It was removed immediately by endoscopy. The patient was able to take a solid diet orally for the next 19 months, while receiving systemic chemotherapy.

CONCLUSIONS

Duodenal stent placement proved useful in a patient who showed response to chemotherapy, despite the need for management of late complications. This approach is expected to be a first-line treatment option for gastric outlet obstruction caused by inoperable gastric cancer.

[A Case of Peritoneal Metastasis of Breast Cancer Diagnosed by Laparoscopic-Assisted Right Hemicolectomy]

The patient was an 86-year-old woman. She underwent right breast-conserving surgery and sentinel lymph node biopsy for breast cancer in August 2006. The pathological diagnosis was invasive ductal carcinoma, T1N0M0, Stage Ⅰ, ER (+), PgR (-), HER2 (-). She was treated with tamoxifen for 5 years as adjuvant therapy and showed no signs of recurrence. In November 2014, CA15-3 was elevated and an accumulation of FDG in the right paracolic sulcus was observed on PET-CT. Peritoneal metastasis of breast cancer was suspected, and an operation was performed for a definitive diagnosis. During the operation, the tumor was seen on the paracolic sulcus, and laparoscopic-assisted right hemicolectomy was performed. A poorly differentiated adenocarcinoma was diagnosed by pathological examination, and immunostaining results were as follows: CK7(+), CK20(-), mammaglobin (-), GCDFP-15 (-), ER (-), PgR (-), and HER2 (-). Because there was no original lesion other than the breast cancer, the tumor was diagnosed as a metastasis of breast cancer. The frequency of peritoneal metastasis of breast cancer is low. In this case, pathological diagnosis was necessary for a definitive diagnosis. A change of subtype was also confirmed, and the treatment strategy was decided appropriately. Surgical resection should be considered for peritoneal metastasis of breast cancer when the operation can be performed safely.

[FOLFIRINOX Combination Chemotherapy in Patients with Metastatic or Recurrent Pancreatic Cancer--A Single Institution Experience]

Pancreatic adenocarcinoma is one of the leading causes of cancer-related deaths in Japan. oxaliplatin: L-OHP, irinotecan: CPT-11, fluorouracil: 5-FU, and Leucovorin: l-LV (FOLFIRINOX) combination chemotherapy provided significant improvements in overall and progression-free survival in a phase Ⅲ trial in France and in a phase Ⅱ trial in Japan. As a result, this combination therapy was approved for use in Japan. We evaluated the efficacy of FOLFIRINOX in metastatic or recurrent pancreatic cancer. Between October 2014 and July 2015, 10 patients received mFOLFIRINOX as follows: 2-hour infusion of LOHP at 85 mg/m2, 2-hour infusion of l-LV at 200 mg/m2 and infusion of CPT-11 over 90 min at 150 mg/m2, followed by continuous infusion of 5-FU over 46 hours at 2,400mg/m2. Prior to the treatment, a 5-hydroxytryptamine receptor antagonist, aprepitant, and dexamethasone were given. The treatment was repeated every 2 weeks until disease progression, unacceptable toxicity, discontinuation as decided by the investigators, or patient refusal. The mean age of the patients was 65.0 years (range, 59-75 years), and 4 out of 10 patients were men. Only 2 patients had no prior therapy. Nine patients had an Eastern Cooperative Oncology Group (ECOG) performance status (PS) of 0. Eight patients had metastasis and 2 had locally recurrent disease. The median number of treatment cycles was 5 (range, 1-14). The relative dose intensities of 5-FU, L-OHP and CPT-11 were 93.3% (range, 58.3-100%), 84.0% (range, 63.2-100%), and 76.0% (range, 44.4-83.3%), respectively. The major Grade 3 and 4 hematological toxicities were neutropenia (40%), leucopenia (30%), and thrombocytopenia(10%). The major Grade 2 and 3 non-hematological toxicities were diarrhea (30%), nausea (60%), and vomiting (10%). Serious adverse events occurred in 2 patients. Severe biliary tract infection causing sepsis was observed in 1 patient with a biliary stent. Overwhelming post-splenectomy infection was observed in 1 patient after distal pancreatectomy. No cases of interstitial lung disease were observed. The 6-month progression-free and overall survival rates were 59.3% and 61.7%, respectively. The overall response rate was 10%, and the disease control rate was 90%(complete response [CR], n=0; partial response [PR], n=1; stable disease [SD], n=8; progressive disease [PD], n=1). Although FOLFIRINOX is associated with increased treatment efficacy and survival outcomes, because of its severe toxicity it cannot be administered to all patients. FOLFIRINOX can be used as the standard treatment for patients with a good performance status.

[Laparoscopic Liver Resection for HCC Recurrence]

Laparoscopic surgery is less invasive and provides better cosmetic outcomes than conventional surgery. Laparoscopic liver resection has been covered by insurance since April 2010 and is increasingly performed in many hospitals. However, laparoscopic hepatectomy is sometimes difficult to perform safely in the case of HCC recurrence because adhesions restrict vision and manipulation of forceps. We report the results of laparoscopic hepatectomy for cases of HCC recurrence. From June 2010 through December 2014, 180 laparoscopic hepatectomy procedures for HCC were performed in our hospital; 33 were in patients with HCC recurrence. Of the 33 patients, 26 underwent pure laparoscopic partial hepatectomy. The median operative time was 242 min, the median bleeding amount was less than 5 g, and the median hospital stay after surgery was 12.0 days. In the group that underwent laparoscopic hepatectomy after open liver resection (12 patients), the median operative time was 303.5 min, the median bleeding amount was less than 5 g, and the median hospital stay after surgery was 9.0 days. Among the 21 patients that underwent laparoscopic hepatectomy after laparoscopic liver resection, the median operative time was 248 min (p=0.382), the median bleeding amount was less than 5 g (p=0.112), and the median hospital stay after surgery was 11.0 days (p=0.236). We could perform laparoscopic hepatectomy for cases of HCC recurrence. This procedure can be suitable for HCC recurrence, which sometimes requires poly-surgery.

[Nab-Paclitaxel plus Gemcitabine for Metastatic Pancreatic Cancer]

Pancreatic ductal carcinoma is a highly aggressive cancer, with one of the highest mortality rates among gastrointestinal cancers. Nab-paclitaxel plus gemcitabine (GEM) significantly improved overall survival, progression-free survival, and response rate in a phase Ⅲ trial in 151 community and academic centers in 11 countries. As a result, nab-paclitaxel plus GEM was approved for use in December 2014 in Japan. We report a case of a patient with pancreatic cancer who underwent this chemotherapy. A 47-year-old man was admitted to our hospital for evaluation of pancreatic lesions. Computed tomography revealed a hypoattenuating tumor in the body of the pancreas. After the patient underwent preoperative chemoradiotherapy under the diagnosis of cStage Ⅳa cancer, we planned to perform distal pancreatectomy. However, this case was inoperable because we found 3 liver metastases during surgery. On postoperative day 14, we treated the patient with nab-paclitaxel plus GEM. Grade 2 toxicities included neutropenia, diarrhea, and peripheral neuropathy, but serious adverse events did not occur. The progression-free survival was 5 months. He remained alive for 7 months after the chemotherapy. In patients with metastatic pancreatic adenocarcinoma, nab-paclitaxel plus GEM can be considered as the standard treatment.

A clinical trial of autologous adipose-derived regenerative cell transplantation for a postoperative enterocutaneous fistula

PURPOSE

Adipose-derived stem cell (ADSC) transplantation is expected to be a minimally invasive, but effective, treatment for postoperative enterocutaneous fistulas associated with poor blood flow and chronic inflammation. The aim of this study was to assess the safety and efficacy of a novel ADSC therapy for this condition.

METHODS

We conducted an open-label, single-arm exploratory phase I study to assess the safety and efficacy of a novel ADSC therapy. Using the Celution system, we isolated adipose-derived regenerative cells (ADRCs) containing abundant ADSCs from liposuction-obtained gluteal adipose tissue. A mixture of ADRCs and fibrin glue was subsequently transplanted into the fistula, and ADRCs were percutaneously and endoscopically injected around the fistula. We evaluated the safety and feasibility of ADRC transplantation and fistula closure in six patients (UMIN000007316).

RESULTS

ADRC transplantation was completed in all patients. The fistula closure rates were 83.3 % at 4 and 12 weeks and 100 % at 24 weeks. All patients had grade 1 pain and subcutaneous hemorrhage at the liposuction sites, but no serious adverse events related to this procedure were observed.

CONCLUSIONS

Transplantation of autologous ADRCs is safe, feasible and advantageous, as it can secure a sufficient cell count without culture or multiple passages, and will likely be effective for a postoperative enterocutaneous fistula.

Manipulations of extracellular Loop 2 in α1 GlyR ultra-sensitive ethanol receptors (USERs) enhance receptor sensitivity to isoflurane, ethanol, and lidocaine, but not propofol

We recently developed ultra-sensitive ethanol receptors (USERs) as a novel tool for investigation of single receptor subunit populations sensitized to extremely low ethanol concentrations that do not affect other receptors in the nervous system. To this end, we found that mutations within the extracellular Loop 2 region of glycine receptors (GlyRs) and γ-aminobutyric acid type A receptors (GABAARs) can significantly increase receptor sensitivity to micro-molar concentrations of ethanol resulting in up to a 100-fold increase in ethanol sensitivity relative to wild-type (WT) receptors. The current study investigated: (1) Whether structural manipulations of Loop 2 in α1 GlyRs could similarly increase receptor sensitivity to other anesthetics; and (2) If mutations exclusive to the C-terminal end of Loop 2 are sufficient to impart these changes. We expressed α1 GlyR USERs in Xenopus oocytes and tested the effects of three classes of anesthetics, isoflurane (volatile), propofol (intravenous), and lidocaine (local), known to enhance glycine-induced chloride currents using two-electrode voltage clamp electrophysiology. Loop 2 mutations produced a significant 10-fold increase in isoflurane and lidocaine sensitivity, but no increase in propofol sensitivity compared to WT α1 GlyRs. Interestingly, we also found that structural manipulations in the C-terminal end of Loop 2 were sufficient and selective for α1 GlyR modulation by ethanol, isoflurane, and lidocaine. These studies are the first to report the extracellular region of α1 GlyRs as a site of lidocaine action. Overall, the findings suggest that Loop 2 of α1 GlyRs is a key region that mediates isoflurane and lidocaine modulation. Moreover, the results identify important amino acids in Loop 2 that regulate isoflurane, lidocaine, and ethanol action. Collectively, these data indicate the commonality of the sites for isoflurane, lidocaine, and ethanol action, and the structural requirements for allosteric modulation on α1 GlyRs within the extracellular Loop 2 region.

RFPL4A increases the G1 population and decreases sensitivity to chemotherapy in human colorectal cancer cells

Cell cycle-arrested cancer cells are resistant to conventional chemotherapy that acts on the mitotic phases of the cell cycle, although the molecular mechanisms involved in halting cell cycle progression remain unclear. Here, we demonstrated that RFPL4A, an uncharacterized ubiquitin ligase, induced G1 retention and thus conferred decreased sensitivity to chemotherapy in the human colorectal cancer cell line, HCT116. Long term time lapse observations in HCT116 cells bearing a "fluorescence ubiquitin-based cell cycle indicator" identified a characteristic population that is viable but remains in the G1 phase for an extended period of time (up to 56 h). Microarray analyses showed that expression of RFPL4A was significantly up-regulated in these G1-arrested cells, not only in HCT116 cells but also in other cancer cell lines, and overexpression of RFPL4A increased the G1 population and decreased sensitivity to chemotherapy. However, knockdown of RFPL4A expression caused the cells to resume mitosis and induced their susceptibility to anti-cancer drugs in vitro and in vivo. These results indicate that RFPL4A is a novel factor that increases the G1 population and decreases sensitivity to chemotherapy and thus may be a promising therapeutic target for refractory tumor conditions.

Calm1 signaling pathway is essential for the migration of mouse precerebellar neurons

The calcium ion regulates many aspects of neuronal migration, which is an indispensable process in the development of the nervous system. Calmodulin (CaM) is a multifunctional calcium ion sensor that transduces much of the signal. To better understand the role of Ca(2+)-CaM in neuronal migration, we investigated mouse precerebellar neurons (PCNs), which undergo stereotyped, long-distance migration to reach their final position in the developing hindbrain. In mammals, CaM is encoded by three non-allelic CaM (Calm) genes (Calm1, Calm2 and Calm3), which produce an identical protein with no amino acid substitutions. We found that these CaM genes are expressed in migrating PCNs. When the expression of CaM from this multigene family was inhibited by RNAi-mediated acute knockdown, inhibition of Calm1 but not the other two genes caused defective PCN migration. Many PCNs treated with Calm1 shRNA failed to complete their circumferential tangential migration and thus failed to reach their prospective target position. Those that did reach the target position failed to invade the depth of the hindbrain through the required radial migration. Overall, our results suggest the participation of CaM in both the tangential and radial migration of PCNs.

[A case of solitary fibrous tumor from the greater omentum resected via laparoscopic surgery]

Solitary fibrous tumor (SFT) are relatively rare neoplasms that usually arise in the thoracic cavity in adults. Although many cases of extrathoracic SFT have been recently reported, SFT from the omentum is rare. A 32-year-old woman consulted a gynecologist complaining of irregular vaginal bleeding. Magnetic resonance imaging (MRI) revealed a tumor in the omentum, and the patient was admitted to our department. The patient underwent laparoscopic tumorectomy. The tumor size was 48 × 35 × 30 mm, and grayish-white nodules were observed. Histological examination showed hyperplastic spindle-shaped tumor cells with a pattern-less arrangement. Immunohistochemical staining showed the tumor was positive for CD34 and bcl-2, slightly positive for alpha smooth muscle actin(a-SMA), and negative for S-100 and c-kit. Accordingly, a diagnosis of SFT was made. The patient has not shown any recurrence 12 months after surgery. Most SFTs are benign, although there are some reports of recurring tumors. There are no clear guidelines for the treatment of SFT because of its rarity. Therefore, close long-term follow-up should be performed.

[A case of pathological complete response with neoadjuvant XELOX chemotherapy for locally advanced rectal cancer]

A 70-year-old man presenting with melena was referred to our clinic. A clinical examination revealed a bulky tumor in the lower rectum. After ileostomy, 4 courses of capecitabine plus oxaliplatin (XELOX) therapy were administered as neoadjuvant chemotherapy. Computed tomography (CT) revealed significant reduction of the tumor. Laparoscopic super-low anterior resection with lateral lymph node dissection was performed. The pathological examination revealed no residual cancer cells, and a diagnosis of pathological complete response was made. The patient has been disease-free for 1 year after the operation. Neoadjuvant chemotherapy with XELOX might be promising for patients with locally advanced rectal cancer.

Interferon-α acts on the S/G2/M phases to induce apoptosis in the G1 phase of an IFNAR2-expressing hepatocellular carcinoma cell line

Interferon-α (IFN-α) is used clinically to treat hepatocellular carcinoma (HCC), although the detailed therapeutic mechanisms remain elusive. In particular, IFN-α has long been implicated in control of the cell cycle, but its actual point of action has not been clarified. Here, using time lapse imaging analyses of the human HCC cell line HuH7 carrying a fluorescence ubiquitination-based cell cycle indicator (Fucci), we found that IFN-α induced cell cycle arrest in the G0/G1 phases, leading to apoptosis through an IFN-α type-2 receptor (IFNAR2)-dependent signaling pathway. Detailed analyses by time lapse imaging and biochemical assays demonstrated that the IFN-α/IFNAR2 axis sensitizes cells to apoptosis in the S/G2/M phases in preparation for cell death in the G0/G1 phases. In summary, this study is the first to demonstrate the detailed mechanism of IFN-α as an anticancer drug, using Fucci-based time lapse imaging, which will be informative for treating HCC with IFN-α in clinical practice.

Feasibility of Chemotherapy in Patients with Inflammatory Bowel Disease-Related Gastrointestinal Cancer

BACKGROUND/AIMS

Long-standing inflammatory bowel disease (IBD), including ulcerative colitis (UC) and Crohn disease (CD), is a known risk factor for gastrointestinal (GI) cancer, especially colorectal cancer (CRC). However, the feasibility of chemotherapy for IBD-related GI cancer is not well understood in terms of efficacy and adverse events, because there are fewer GI cancer patients with IBD than without IBD.

METHODOLOGY

We retrospectively analyzed the medical records of eight IBD patients (CD = 5 and UC = 3) who received chemotherapy for IBD-related GI cancer between April 2003 and March 2013.

RESULTS

The most common gastrointestinal adverse event was diarrhea (75%); 38% of patients experienced grade 3 diarrhea. Moreover, all grade 3 diarrhea occurred in patients with CD. The most common hematologic adverse events were anemia (75%), leukopenia (38%), and neutropenia (30%); 25% of patients experienced grade 3 neutropenia. The other severe adverse events were grade 3 AST and ALT elevation (13%).

CONCLUSIONS

In this study, the incidence of grade 3 diarrhea was higher in patients with CD. The length and dysfunction of the small intestine is the most likely reason that diarrhea occurred more frequently in patients with CD.

Cell cycle-dependent Rho GTPase activity dynamically regulates cancer cell motility and invasion in vivo

The mechanism behind the spatiotemporal control of cancer cell dynamics and its possible association with cell proliferation has not been well established. By exploiting the intravital imaging technique, we found that cancer cell motility and invasive properties were closely associated with the cell cycle. In vivo inoculation of human colon cancer cells bearing fluorescence ubiquitination-based cell cycle indicator (Fucci) demonstrated an unexpected phenomenon: S/G2/M cells were more motile and invasive than G1 cells. Microarray analyses showed that Arhgap11a, an uncharacterized Rho GTPase-activating protein (RhoGAP), was expressed in a cell-cycle-dependent fashion. Expression of ARHGAP11A in cancer cells suppressed RhoA-dependent mechanisms, such as stress fiber formation and focal adhesion, which made the cells more prone to migrate. We also demonstrated that RhoA suppression by ARHGAP11A induced augmentation of relative Rac1 activity, leading to an increase in the invasive properties. RNAi-based inhibition of Arhgap11a reduced the invasion and in vivo expansion of cancers. Additionally, analysis of human specimens showed the significant up-regulation of Arhgap11a in colon cancers, which was correlated with clinical invasion status. The present study suggests that ARHGAP11A, a cell cycle-dependent RhoGAP, is a critical regulator of cancer cell mobility and is thus a promising therapeutic target in invasive cancers.

[Focal nodular hyperplasia that was difficult to differentiate from hepatocellular carcinoma]

A 59-year-old man had received medical treatment for alcoholic hepatopathy. He stopped drinking 3 years before visiting the hospital. On medical examination, the abdominal echo showed a hepatic mass lesion that was HBs-Ag (-) and HCV-Ab (-). Computed tomography (CT) revealed a tumor of more than 25 mm in diameter at S7 of the liver. Dynamic CT showed that it was stained in the early phase but washed out in the delay phase. Magnetic resonance imaging (MRI) showed high intensity staining of the tumor in both T1-and T2-weighted images, and it was also stained in the EOB Primovist MRI hepatobiliary phase. The findings from the images were not typical for hepatocellular carcinoma(HCC) or other benign tumors. We therefore performed an S7 partial hepatectomy. We diagnosed the tumor as focal nodular hyperplasia (FNH) by histology.

[A case of invasive ductal carcinoma of the pancreas originating from an intraductal papillary mucinous tumor that was initially misdiagnosed as a mucinous cystic tumor]

A 57-year-old woman was discovered to have a cystic tumor, 8 cm in diameter, at the pancreas tail, during routine screening with ultrasonography. The patient did not complain of tenderness, and no abdominal mass was palpable at physical examination. Enhanced computed tomography(CT) revealed that the tumor had mural nodules in the cyst wall, and we suspected it to be a malignant tumor that had occurred in the mucinous cystic neoplasm(MCN). Therefore, surgical resection was attempted, upon which the tumor was found to be hard and the surrounding tissue adhered widely to the stomach. We separated it carefully from the stomach and then performed a distal pancreatectomy. The cut surface revealed that the posterior wall of the cystic tumor was partly thickened, and microscopic examination revealed it to be invasive ductal carcinoma. No ovarian-like stroma was involved and some degree of dysplasia(PanIN 1-3) was found in the neighboring tissues. Therefore, we re-diagnosed it to be invasive ductal carcinoma of the pancreas derived from intraductal papillary mucinous tumor(IPMT), not from MCN. The patient received adjuvant chemotherapy, although 5 months later multiple lung metastases had appeared. The international consensus guidelines for management of IPMN and MCN of the pancreas suggest that they can usually be distinguished preoperatively, if there is a complete understanding of their clinical and imaging features. However, we sometimes find it difficult to distinguish the 2, because some IPMN or MCN cases have shared preoperative features. Herein, we report the case of invasive ductal carcinoma of the pancreas derived from IPMT that was originally misdiagnosed as a MCN.

[Total pancreatectomy for pancreatic head cancer accompanied with multiple lesions]

Our patient was a 67-year-old man, with a chief complaint of brown urine. He subsequently underwent medical examination in June. Because the results of his blood examination revealed liver dysfunction, he was admitted to our hospital for further careful examination. An abdominal computed tomography(CT) scan showed the presence of a pancreas tumor, with a diameter of 2 cm, at the pancreas head, as well as common biliary duct dilatation and main pancreatic duct dilation from the head to the tail of the pancreas. The patient was diagnosed with pancreatic cancer[cT3( CH+, DU+), cN0, cM0, cStage III], with obstructive jaundice. After biliary drainage, we performed laparotomy in August. During the operation, other than the tumor on the pancreas head, identified at the preoperative diagnosis, we found 2 white nodules on the pancreas surface. One nodule was located at the body of the pancreas and the other, at its tail. On intraoperative pathological examination of the nodules, they were found to be invasive ductal carcinomas. On the basis of these findings, we suspected multiple cancers or overall pancreatic cancer; therefore, we performed total pancreatectomy, not pancreaticoduodenectomy (PD). We choose pancreatectomy over PD because it was impossible to confirm the cancerous area. Pathological examination of the resected specimen did not reveal any malignant lesion. Thus, if we had not performed pancreatectomy, assuming that the pancreas body or tail had no cancer lesion, based on the pathological examination result, the cancer would have persisted. Further, careful examination involving inspection and palpation is considered to be essential before resection of the pancreas tumor.

[Laparoscopic reconstruction of jejunostomy catheter deviations in gastric and esophageal cancer patients who underwent jejunostomy]

Jejunostomy feeding is useful for maintaining nutrition in patients with gastric cancer and esophageal cancer. Special provisions must be made in cases of occlusion or dislocation of the jejunostomy catheter, and when the catheter is narrow and difficult to approach by endoscopy. Between 2007 and 2011, we encountered 69 cases of jejunostomy: 40 performed for gastric cancer and 29 for esophageal cancer. Catheter occlusion was seen in 7 cases and catheter dislocation in 9. Of these 16 cases, 14 could be recovered using interventional radiology (IVR), and the remaining 2 could not be because of fistel closure.

[A surgical case of solitary lymph node metastasis of hepatocellular carcinoma after nonsurgical treatment]

A 66-year-old man with multiple hepatocellular carcinomas(HCCs) underwent transcatheter arterial chemoembolization(TACE) twice and radiofrequency ablation(RFA) twice at another hospital in June 2009. In November 2010, abdominal computed tomography(CT) revealed a solitary lymph node metastasis( 23 mm in diameter) in the hepatoduodenal ligament, after which he was admitted to our hospital in December 2010. In February 2011, ethoxybenzyl diethylenetriamine pentaceric acid-enhanced magnetic resonance imaging (EOB-MRI) showed revealed a growing solitary lymph node metastasis(33 mm in diameter) and good control of the intrahepatic lesion. Positron emission tomography(PET)-CT confirmed the solitary lymph node metastasis without any other extrahepatic recurrence. We performed lymph node resection in March 2011 because of good control of the intrahepatic lesion and the lack of extrahepatic recurrence. He was discharged from our hospital 11 days after surgery with a good postoperative course. Histologically, the tumor was diagnosed as a lymph node metastasis of poorly differentiated HCC. Subsequent abdominal CT in January 2012 revealed multiple recurrent lesions, and he underwent TACE therapy in February 2012. Currently, the patient is alive 1 year 3 months after lymph node resection without any other extrahepatic recurrence.

[A case of pancreatic mucinous carcinoma which includes calcification]

A 60-year-old woman was pointed out a tumor, 2.6 cm in diameter, at the pancreas body, by screening ultrasonography examination. Jaundice and anemia were absent and no abdominal mass was palpable on physical examination. Enhanced CT revealed the tumor directly invaded to splenic vein, but lymph node metastases were not detected. ERCP showed a pancreatic duct was obstructed by the tumor, accompanied with dilatation of the peripheral pancreas duct. Because we cannot rule out the malignancy tumor, pancreatoduodenectomy and lymphadenectomy was done. The tumor was very hard and serosal invasion was suspicious in the operative findings. Histopathological study showed that the tumor was occupied with colloid differentiation, in which free mucinous epithelial malignant cells were floating. Then we diagnosed the tumor to be pancreatic mucinous carcinoma. Extra pancreatic extension such as vascular involvement was not proved microscopically. However, ten months after the resection, CT scan showed a recurrent tumor sized 4 cm diameter, at the middle abdominal cavity, which suspected to be disseminated diseases. Mucinous carcinoma occurs relatively rare in pancreas, of which the incidence is 1 .4% in pancreatic adenocarcinomas. We report herein the pancreatic mucinous carcinoma case with a calcificated region, which resulted in early recurrence with abdominal seeding.

[Gallbladder carcinomas with a single lymph node involvement behind biliary tract -two resected cases]

Case 1 was an 85-year-old man, who was pointed out a gallbladder tumor by screening CT scan after bladder cancer. The tumor was arisen in the gallbladder body, 1 .5 cm in diameter. He underwent a radical surgery; the gallbladder-bed was resected with more than 1 cm margin, and lymphadenectomy was done preserving biliary tract. Pathologically his tumor was papillary adenocarcinoma suspected to invade to the liver-bed minimally. A lymph node involvement was solitary located at right side of hepatoduodenal ligament (behind biliary tract). Case 2 was a 73-year-old man who was pathologically diagnosed to be advanced gallbladder carcinoma after laparoscopic cholecystectomy. CT scan and MRI revealed a mass sized 2 cm in diameter, at the gallbladder-bed, and PET exam showed a hot spot at this site only. Therefore, he underwent a radical surgery like case 1. Pathologically the tumor was moderately differentiated adenocarcinoma, and a lymph node involvement was solitary and located behind a biliary tract. Both patients have been recurrent free for more than 22 months and 15 months, respectively. Two lymphatic drainage routes have been suggested, one is the route which runs right side of hepatoduodenal ligament, another runs via left side of the ligament, along hepatic artery. Our two cases are considered to be solitary metastatic cases along the right side route. A clinical case of solitary node positive seems to be known for its relatively good prognosis. In order to justify our cases, we need a longer follow-up period, or we should have more cases to be experienced.

Late-onset circulatory dysfunction after thyroid hormone treatment in an extremely low birth weight infant

Late-onset circulatory dysfunction (LCD) is a phenomenon specific to premature infants and is characterized by sudden onset of hyponatremia, hypotension, oliguria and non-physiological weight gain, without an obvious cause, in premature infants after stabilization of circulation and respiration. The cause of LCD is not clear, but adrenal insufficiency in premature infants is a severe syndrome because steroid replacement therapy is often essential to treat the symptoms. We report a rare case of a premature infant who developed an LCD crisis the day after thyroxine replacement therapy. The female infant was born at 25 weeks of gestational age, weighing 672 g, and appeared to have hypothyroidism, with free T4 of 0.19 ng/dl and elevated TSH levels of 26.3 microIU/ml at Day 14. She developed an LCD crisis the day after starting thyroxine treatment. She received steroid replacement therapy for 4 weeks and her adrenal function progressively recovered. She also needed thyroxine supplementation for 13 weeks, which maintained her thyroid function as euthyroid. Because she exhibited cortisol insufficiency and thyroid hormone insufficiency, the antecedent thyroid hormone replacement may be responsible for the onset of LCD. We must consider monitoring adrenal function when starting thyroxine therapy in premature infants with hypothyroxinemia.

Electron paramagnetic resonance studies on spin-labelling of pepsin: effects of temperature, pH and urea on its conformation

Pepsin was spin-labelled with N-(1-oxyl-2,2,6,6-tetramethyl-4-piperidyl) bromoacetamide, possibly at the active site, at a beta-catboxyl group of a reactive aspartic acid. The spectrum of the spin-labelled pepsin showed that the spin probe was strongly immobilized (correlation time is greater than or equal to 10(-8) sec). Spin-labelled pepsin was thermally denatured at various temperatures and electron paramagnetic resonance (e.p.r.) spectra were taken at various times. Rates of denaturation estimated from the e.p.r. spectra at various temperatures showed that the enthalpy and entropy of thermal denaturation of spin-labelled pepsin at pH 3.5 were 48.0+/-4.9 kcal/mole and 214.7+/-14.5 e.u. respectively. Addition of conc. NaOH or 1 M acetate buffer at pH 6.0 sharpened e.p.r. spectra of the spin-labelled pepsin, indicating that the spin probe became mobilized by alkaline denaturation. Addition of urea caused unfolding of the protein which increased with the urea concentration, although only slight transition of conformational changes was observed in the e.p.r. spectra.

Lipid peroxides induce early onset of catagen phase in murine hair cycles

The precise mechanisms of alopecia, a pathophysiological disorder with negative psychological implications, are unknown. Androgen and hereditary predisposition are major causes, but the condition is also affected by stress, an irregular diet and high levels of sebum secretion. We focused on oxidative stress and analyzed the effect of the lipid peroxides on hair follicles. Our first observation was that the topical application of linolein hydroperoxides, one of the lipid peroxides, lead to the early onset of the catagen phase in murine hair cycles. Furthermore, by using TUNEL staining we found that lipid peroxides induced apoptosis of hair follicle cells. They also induced apoptosis in human epidermal keratinocytes by up-regulating apoptosis-related genes. These results indicated that lipid peroxides, which can cause free radicals, induce the apoptosis of hair follicle cells, and this is followed by early onset of the catagen phase. These observations may provide insight into the mechanisms underlying the development of alopecia in humans.

Dihydrotestosterone inhibits murine hair growth via the androgen receptor

BACKGROUND

Androgens cause regression of human hair follicles in the parietofrontal scalp, but the precise mechanisms by which they do so are unknown. Although many investigators have elucidated the effect of androgens on hair growth by using rodents and other animals, some of the evidence is conflicting.

OBJECTIVES

To investigate the effect of androgens on mouse hair regrowth and hair cycle by using androgen receptor knockout (ARKO) mice. Methods We examined the effects of dihydrotestosterone (DHT) on hair regrowth by using ARKO mice and wild-type (WT) littermates, compared the hair cycles in ARKO mice and WT littermates by histology and histomorphometry, and measured hair length and thickness in ARKO mice and WT littermates.

RESULTS

DHT inhibited the hair regrowth of WT mice but not that of their ARKO littermates. The anagen phase in the second hair cycle was longer in ARKO mice than in their WT littermates. The hair of ARKO mice was longer and thicker than that of their WT littermates.

CONCLUSIONS

Androgens inhibit hair growth in mice, and this inhibition might be caused by androgen-androgen receptor signals.

Increased mitochondrial DNA induces acquired docetaxel resistance in head and neck cancer cells

Docetaxel is one of the most effective chemotherapeutic agents against cancer; nevertheless, some patients develop resistance. Unfortunately, their causes and mechanisms remain unknown. We created docetaxel-resistant DRHEp2 from human laryngeal cancer HEp2 and investigated the roles of mitochondrial DNA (mtDNA) and reactive oxygen species (ROS) on docetaxel resistance. DRHEp2 had greatly increased mtDNA content. Reduction of mtDNA content in DRHEp2 by ethidium bromide treatment reduced the resistance. These results indicate the possible roles of mtDNA-coded enzymes in mitochondrial respiratory chain (MRC) in resistant mechanisms. Oligomycin A, an Fo-ATPase inhibitor, eliminated docetaxel resistance in DRHEp2; in contrast, inhibitors of other MRC did not. RNA interference targeted to Fo-ATPase d-subunit restored docetaxel-induced cytotoxicity to DRHEp2. These results indicate the roles of Fo-ATPase for resistant mechanisms. Docetaxel induced ROS generation in HEp2 but not in DRHEp2 and antioxidant pyrrolidine dithiocarbamate eliminated docetaxel-induced cytotoxicity, suggesting roles of ROS in docetaxel-induced cell death. Furthermore, inhibition of Fo-ATPase by Oligomycin A induced docetaxel-mediated ROS generation in DRHEp2. Taken together, DRHEp2 acquired docetaxel resistance through increasing Fo-ATPase, which led to diminish docetaxel-induced ROS generation and subsequently inhibited cell death. In conclusion, mtDNA plays an important role in developing docetaxel resistance through the reduction of ROS generation by regulating Fo-ATPase.

Stanniocalcin 1 prevents cytosolic Ca2+ overload and cell hypercontracture in cardiomyocytes

BACKGROUND

The aim of the present study was to examine whether stanniocalcin 1 (STC1) affects cardiomyocytes under physiological or pathophysiological conditions.

METHODS AND RESULTS

Using fresh isolated rat cardiomyocytes, the effects of STC1 on cell hypercontracture, cell shortening and Ca(2+) transients were measured after exposing the cells to ouabain. STC1 alone did not affect cell shortening or the Ca(2+) transient. Exposure to ouabain significantly increased the fraction of hypercontractured cells (40.5+/-1.4% vs 3.5+/-1.7% in the control, p<0.01). However, treatment with STC1 decreased the percentage of cell hypercontracture that was induced by ouabain, in a concentration-dependent manner (17.4+/-2.6% at 2.5 nmol/L STC1, p<0.01). Moreover, STC1 prevented the increase in diastolic intracellular Ca(2+) level that was induced by ouabain (-5.3+/-2.7% vs 7.9+/-3.7% induced by ouabain, p<0.05; -15.3+/-5.1% in the control) in the cardiomyocytes.

CONCLUSIONS

STC1 prevented the increase in diastolic Ca(2+) overload and ouabain-induced cell hypercontracture, which suggests that STC1 could effectively prevent cytosolic Ca(2+) overload and protect cardiomyocytes from pathophysiological conditions such as in the failing heart.

Balloon angioplasty for ductus arteriosus in infant with ductal origin of the left pulmonary artery: combination with nitrogen inhalation therapy

An infant with truncus arteriosus (Van Praagh A3; isolated left pulmonary artery (LPA) and ductal origin of the LPA) had an extremely stenotic ductus arteriosus (DA) and the LPA could not be demonstrated. As a salvage operation, balloon angioplasty was performed for the stenotic DA at 8 days of age. The minimum lumen diameter of the DA increased from 0.7 to 2.7 mm. After the procedure, the LPA tree was well demonstrated and total pulmonary blood flow increased. Nitrogen inhalation was begun with a nasal positive airway pressure system in order to regulate pulmonary blood flow. Repeat balloon angioplasty was performed at 33 days of age for the restenosed DA. The infant's general condition was stabilized until undergoing pulmonary artery reconstruction and modified Blalock-Taussig shunt at 4 months of age, and definitive repair at 11 months of age. The combination of balloon angioplasty and nitrogen inhalation therapy enabled simultaneous growth of the LPA tree and regulation of total pulmonary blood flow, which could be a useful strategy for complex congenital heart diseases with unbalanced pulmonary blood flow.

Preoperative portal vein embolization with a mixture of gelatin sponge and iodized oil: efficacy and safety

PURPOSE

To evaluate whether portal vein embolization (PVE) using a mixture of gelatin sponge (GS) pieces and iodized oil is safe and effective in inducing hypertrophy of the future liver remnants (FLR).

MATERIAL AND METHODS

PVE was performed in 14 patients (eight male and six female, mean age 65 years, range 35-81 years) diagnosed with malignant liver tumor before surgery, whose FLR volumes were judged too small to allow for safe resection. Liver volume change, biochemical data change, complications related to PVE, and postoperative complications were retrospectively evaluated.

RESULTS

PVE was successful in all patients, and there were no procedural complications. Absolute FLR volume and FLR/total liver volume (TLV) ratio increased by 102 cm3 and 8% (mean values), respectively. Planned hepatectomies were cancelled in three patients due to extrahepatic metastasis or bile duct infection. Five of the 11 patients (45%) who underwent hepatectomies had major postoperative complications. However, complications due to hepatic failure were not seen. In 10 patients, except one whose outcome was fatal outcome, the mean hospitalization days with and without major complications were 73 and 33 days, respectively.

CONCLUSION

PVE using a mixture of GS and iodized oil seems to be effective and safe in inducing hypertrophy of the FLR.

Hospital nurse administrators in Japan: a feminist dimensional analysis

BACKGROUND

Nursing administration research is scarce in Japan during a time when health care is rapidly reforming and baccalaureate and graduate nursing programmes are rapidly developing. Additionally, nursing administration content relies heavily on Western and non-nursing theories, some of which have been criticized for male bias.

PURPOSE

The purpose of this article is to present key findings from a qualitative study that explored the perspectives or viewpoints of 16 Japanese senior female nurse administrators in hospitals in order to learn what was happening in their working situations and how they were managing.

DESIGN AND METHODS

This feminist study used dimensional analysis strategies for data collection and analysis. Semi-structured, tape-recorded interviews were conducted by both researchers in Japanese, transcribed into Japanese, and translated into English.

RESULTS AND DISCUSSION

The resulting explanatory matrix portrayed a story of 16 nurse administrators, most of whom were able successfully to enact a management role in a context of role ambiguity that was congruent with their relational values and beliefs. Important conditions influencing value-based role enactment included organization mission and purpose, organization structure, nurse-doctor relationships, participant-supervisor relationships, and personal attributes. Many participants were able to overcome barriers in these categories using strategies of tempered radicalism and consequently made positive organizational changes.

CONCLUSIONS

Advanced formal education, better organizational support, and a raised consciousness among nurses that views nurses and midwives as equal partners with other professionals will enable Japanese nurse administrators to help advance patient-centred care and nursing development and empowerment.