[Neoadjuvant chemotherapy for recurrent colorectal cancer]

BACKGROUND

The prognosis after surgical resection of recurrent colorectal cancer is still poor, even if it is diagnosed as "resectable" before operation. Neoadjuvant chemotherapy (NAC) may reduce the recurrence rate after resection of recurrent lesions by ensuring the surgical margin and controlling micro-metastases. This report presents the treatment regimen and outcome of NAC for recurrent colorectal cancer at this institution.

PATIENTS AND METHODS

Nineteen patients with recurrent colorectal cancer, excluding hepatic and pulmonary metastases, received NAC before laparotomy between April 2005 and November 2011. The FOLFIRI3 regimen combined with molecular targeting agents was used for NAC, and 4 to 8 courses were administered. Laparotomy was performed during the 4-to 6-week period after the last NAC administration, and 12 courses of mFOLFOX6 were recommended as adjuvant chemotherapy after the operation.

RESULTS

Complete remission was observed in 1 patient and partial remission in 7 patients according to Response Evaluation Criteria in Solid Tumors ver. 3, and no progressive disease was observed. Curative resection was achieved in 13 patients. The 3-year overall survival rate was 83.6%, and the 3-year relapse-free survival rate was 50.3%.

CONCLUSION

This retrospective study using a small number of subjects suggested that NAC for recurrent colorectal cancer may increase the curative resection rate while reducing the recurrence rate.

Predictive factors of response to intravenous ciclosporin in severe ulcerative colitis: the development of a novel prediction formula

BACKGROUND

When treating patients with severe ulcerative colitis (UC), accurate prediction of drug efficacy contributes to early clinical decision-making.

AIM

To identify predictive factors and to develop a reliable prediction formula and a decision tree of response to intravenous ciclosporin treatment for severe UC.

METHODS

Patients included in this study were those diagnosed with refractory severe UC who had undergone ciclosporin treatment between December 2004 and March 2011 at a tertiary referral centre in Japan. Demographic and clinical parameters from all patients were analysed by multivariate statistics.

RESULTS

Fifty-two patients were included in this study (36.5% men with an average age of ciclosporin initiation of 40.2 ± 15.6 years). Thirty-four patients (65.4%) were responders to the treatment with ciclosporin and avoided colectomy, 18 patients (34.6%) were nonresponders and underwent colectomy. Stepwise multiple logistic regression analysis identified four independent predictive factors of response to intravenous ciclosporin: age at hospitalisation (AGE), platelet count (×10(4) /μL) on the first day (PLA), Lichtiger score on the third day (LIC) and total protein (g/dL) on the third day minus total protein on the first day (ΔTP). The calculation formula (8.5 - 0.16 × AGE + 0.21 × PLA - 0.61 × LIC + 2.3 × ΔTP < 0) predicted colectomy with an accuracy of 88.5% and the decision tree predicted colectomy with an accuracy of 90.4%.

CONCLUSION

The novel calculation formula and the decision tree effectively predict the clinical outcome of ciclosporin treatment for severe ulcerative colitis as early as on day 3 after starting ciclosporin treatment.

[A case of recurrent rectal cancer with idiopathic thrombocytopenic purpura showing rapid progression, suggesting disseminated intravascular coagulopathy]

A 64-year-old female with idiopathic thrombocytopenic purpura(ITP)was admitted to our hospital under the diagnosis of rectal cancer. Intersphincteric resection and splenectomy were performed after high-dose gamma globulin therapy. Thirteen months after the surgery, she suffered from a local recurrence and groin and pelvic lymph node metastases. Radiotherapy was planned before curative resection. During radiation, she complained of severe back pain and high fever with severe thrombocytopenia, and was admitted to our hospital. The examinations revealed disseminated intravascular coagulopathy(DIC), probably induced by multiple bone and hepatic metastases. Although anti-DIC therapy and chemotherapy with FOLFIRI were performed, thrombocytopenia did not improve, and she died of cancer progression about 2 months after admission. We report a case ofDIC induced by cancer progression with ITP. Since thrombocytopenia may be induced by either DIC or ITP, selecting a treatment for such a patient is difficult. We report the present case in detail and discuss findings from the literature.

Epigenetic silencing of microRNA-373 plays an important role in regulating cell proliferation in colon cancer

microRNAs (miRNA) are non-coding RNAs that negatively control gene expression by cleaving or inhibiting the translation of target gene mRNAs. We used a microarray-based transcriptomic analysis to identify miRNA expression levels that changed in response to epigenetic factors. Specifically, we searched for increased expression of miRNAs prepared from colon cancer cell line DLD-1 after a 96-h treatment with 5 µM of 5-aza-2'-deoxycytidine (DAC). Among those identified, transient transfection of miRNA hsa-miR-373 resulted in cytostasis. In addition, bisulfate sequence analysis of the promoter regions of these miRNAs showed aberrant methylation in the cancer cells. In clinical colon samples, hsa-miR-373 was down-regulated in colon cancers (29/40, 72.5%) relative to control samples, whereas the purported oncogene RAB22A (a target gene of hsa-miR-373) was up-regulated (24/40, 60%). Using methylation-specific PCR, we also observed aberrant methylation of hsa-miR-373 in colon cancers (35/40, 87.5%) relative to controls (8/40, 20%). Based on these results, we conclude that expression of hsa-miR-373 is down-regulated by aberrant methylation in colon cancer and that this miRNA may function by regulating expression of the oncogene RAB22A.

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

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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.

Inferior head resection of the pancreas for intraductal papillary mucinous neoplasms

BACKGROUND

Previous reports have suggested that patients with intraductal papillary mucinous neoplasm (IPMN) have a favorable prognosis after surgical resection. Thus, a variety of types of partial pancreatic resections have been advocated for treating these low-grade malignant tumors. However, the surgical outcome of IPMN after such limited pancreatectomy has not been fully clarified.

METHODS

We performed a retrospective review of the clinicopathologic features and surgical outcome in 15 patients who underwent inferior head resection for IPMN at the Chiba University Hospital and National Cancer Center Hospital East between July 1994 and January 2007.

RESULTS

There were 13 patients with noninvasive IPMNs (10 adenomas and 3 noninvasive carcinomas) and 2 patients with minimally invasive intraductal papillary mucinous carcinoma (minimally invasive IPMN). Complete tumor removal (R0 resection) was performed in four patients (80%) with intraductal papillary mucinous carcinoma. Subsequent pancreatoduodenectomy was performed in one patient because of noninvasive carcinoma with multiple mucous lakes in the pancreatic parenchyma. Values for N-benzoyl-L: -tyrosyl-p-aminobenzoic acid excretion test results before (n = 13) and after (n = 13) the operation were 70.7 and 66.1, showing no significant difference. The 2-h glucose levels in the 75 g oral glucose tolerance test before (n = 13) and after (n = 13) the operation were 133 and 146 mg/dl, respectively, showing no significant difference. Pancreatic fistula occurred in 7 (47%) patients. Overall morbidity and mortality rates were 67 and 0%, respectively. The overall 1-, 3-, 5-, and 10-year survival rates for the 15 patients were 100, 79, 79, and 71%, respectively. The 1-, 3-, 5-, and 10-year survival rates for patients with noninvasive IPMN (n = 13) and those with minimally invasive IPMN (n = 2) were 100, 92, 92, and 83%; and 100, 0, 0, and 0%, respectively. There was a significant difference in survival between patients with noninvasive IPMN and those with minimally invasive IPMN (p = 0.0005). No patient with noninvasive IPMN developed recurrent disease. One patient with minimally invasive IPMN died of recurrent peritoneal dissemination 18 months after margin-positive R1 resection. Two patients died of pancreatic ductal adenocarcinoma, 30 and 78 months after inferior head resection.

CONCLUSIONS

Pancreatic endocrine and exocrine function was well preserved after inferior head resection. Pancreatic fistula occurred more frequently after inferior head resection than with conventional pancreatoduodenectomy. Patients with noninvasive IPMN had favorable survivals after this procedure. However, one patient with minimally invasive IPMN with margin-positive R1 resection died of recurrent disease. Thus, margin-negative R0 resection should be performed for IPMN.

Mould filling of Ag-Pd-Cu-Au and Ag-Zn-Sn-In alloy castings made using a rapidly prepared gypsum-bonded investment material

Mandibular premolar-shaped wax patterns of full crowns with a marginal angle of 300 were prepared. Two semiprecious alloys were cast using a rapidly prepared gypsum-bonded investment material or a conventional gypsum-bonded investment. A precise impression was taken and cut into four segments. Scanning electron microscopy was used to evaluate the mould filling of each segment. The mould filling of the silver-palladium-copper-gold alloy was worse than that of the silver-zinc-tin-indium alloy. The mould filling of both alloys cast with the rapidly prepared gypsum-bonded investment material was superior to that using the conventional investment.

Characteristic findings on defecography according to reconstruction method and defecatory disorder following sphincter-saving surgery for rectal cancer

BACKGROUND AND AIMS

This study used postoperative defecography to characterize morphological features of defecatory disorders in patients following rectal resection. We also evaluated differences in dynamic defecatory condition depending on reconstruction methods for sphincter-saving surgery.

MATERIALS AND METHODS

Subjects comprised 62 patients (male/female, 41/21; mean age, 61 years) who underwent defecography after sphincter-saving surgery for rectal cancer. Semisolid barium (100 ml) was introduced into the rectum, and images were taken in a sitting position. Characteristic dynamic findings in defecography were evaluated according to operative methods and were compared with symptoms of defecatory disorders.

RESULTS

Defecographic findings closely associated with postoperative defecatory disorder were as follows: (1) low volume of neorectum in patients with worse incontinence grade (p < 0.05), (2) low evacuation fraction in patients with significantly impaired function such as soiling, urgency, and worsened incontinence score (p < 0.05), (3) minor alteration of anorectal angle at evacuation in patients with major soiling and worsened incontinence score (p < 0.05), and (4) barium shadow in the anal canal at rest in patients with urgency (p < 0.05). By reconstruction method, the J-pouch displayed a larger volume than straight anastomosis but a significantly wider anorectal angle than high anterior resection (HAR). Side-to-end anastomosis offered a moderate volume and a sharp anorectal angle as in HAR.

CONCLUSIONS

Defecography is useful for visualizing and characterizing defecatory disorders following rectal resection. Based on defecography, J-pouch reconstruction offers advantageous volume, while side-to-end anastomosis provides a more acute anorectal angle for patients who have received rectal resection with low anastomosis. A new reconstruction method offering both advantages was discussed.

The HLA-A*0201-restricted minor histocompatibility antigen HA-1H peptide can also be presented by another HLA-A2 subtype, A*0206

HA-1(H) is one of the most attractive minor histocompatibility antigens (mHA) as a target for immunotherapy of hematopoietic malignancies, but HLA-A*0201 and HLA-B60 molecules capable of presenting HA-1(H)-derived peptides are less common in eastern Asian populations when compared with Caucasian populations. Therefore, an attempt was made to search for novel epitopes presented by HLA alleles other than those previously reported by generating CTL lines from patients undergoing HLA-identical, HA-1 disparate hematopoietic stem cell transplantation (hematopoietic SCT) by stimulation with a 29-mer HA-1(H) peptide spanning a central polymorphic histidine (His). Two CTL clones established were found to be restricted by HLA-A*0206, which is the second or third most common HLA-A2 subtype worldwide. Epitope mapping revealed that the clones recognized the same nonameric peptide as A*0201-restricted HA-1(H), VLHDDLLEA. This epitope was unexpected, since it does not contain any preferred anchor motifs for HLA-A*0206. However, an HLA peptide binding assay revealed stronger binding of this peptide to A*0206 than to A*0201. Interestingly, HLA-A*0206-restricted CTL clones could lyse both HLA-A*0206(+) and HLA-A*0201(+) targets (including leukemic blasts) that express HA-1(H) peptide endogenously, whereas an HLA-A*0201-restricted, HA-1(H)-specific CTL clone failed to lyse HLA-A*0206(+) targets. This finding will expand the patient population who can benefit from HA-1(H)-based immunotherapy.

Enhanced desensitization efficacy by liposomal conjugation of a specific antigen

Since liposomes are known as strong adjuvants, we attempted to use liposomes in immunotherapy as adjuvants, and to achieve desensitization in pre-sensitized mice. At first, we sensitized mice with intraperitoneal injection of model antigen, 100 microg ovalbumin (OVA), with Alum and treated them with liposome composed of distearoylphosphatidylcholine (DSPC) and cholesterol (2:1 as a molar ratio), which was coupled with a small amount of OVA (10 microg OVA in 400 nmol DSPC and 200 nmol cholesterol-liposome was injected into 20 g mouse). It is well known that antigen-specific immunotherapy increases IgG blocking antibodies and decreases in IgE antibodies. The treatment with i.v. injection of OVA-liposome at days 8, 10, and 12 after sensitization strongly suppressed OVA-specific IgE production without affecting IgG level after the boost (100 microg OVA with Alum). Moreover, the treatment with high-density OVA-liposome (10 microg OVA in 80 nmol DSPC and 40 nmol cholesterol-liposome/20 g mouse) not only strongly suppressed IgE levels but also reduced IgG production after the boost of OVA-sensitized mice suggesting the importance of liposomal characteristic in desensitization immunotherapy. Next we reduced the dose of OVA-liposome and the desensitization effect was also observed at the dose of as low as 1 microg OVA on OVA-liposome/mouse. On the contrary, free OVA did not affect the production of both IgG and IgE levels. Biodistribution study indicated that OVA-liposome was highly accumulated in spleen of OVA-sensitized mice compared to control liposome at 3 h after i.v. injection. These results suggest that the liposomal OVA effectively interacts with and desensitizes immune cells, therefore, liposomes coupling with a certain antigen may be effective in allergy immunotherapy.

Laparoscopic distal pancreatectomy as the total biopsy of the pancreas: tool of minimally invasive surgery

Because of recent progress in imaging modalities, the opportunities to detect pancreatic cystic neoplasms are increasing. However, serous cystadenoma is still uncommon. We report a case of serous cystadenoma treated by laparoscopic distal pancreatectomy. A 52-year-old woman presented with mild upper abdominal pain. Dynamic computed tomography (CT) revealed a solitary cystic lesion 3 cm in diameter in the pancreatic tail. Endoscopic ultrasound showed a honeycomb pattern, indicative of serous cystadenoma. To obtain the final diagnosis of the tumor, we performed laparoscopic distal pancreatectomy. A histopathological study showed microcystadenoma with no evidence of malignancy.

[A case of the 5-year survivor of ascending colon cancer associated with synchronous multiple liver metastasis and peritoneal dissemination successfully treated with combination therapy of systemic and hepatic arterial infusion chemotherapy]

A 67-year-old woman was diagnosed by a series of examinations as having ascending colon cancer with synchronous multiple liver metastasis. She underwent an operation after the PTPE (percutaneous transhepatic portal vein embolization) to the right lobe of the liver, as we considered that the metastatic liver tumors were all resectable. In the surgery, we identified seven peritoneal tumors and a lymph node swelling. We then pathologically diagnosed them as being peritoneal dissemination (p3) and lymph node metastasis (n2(+)). Therefore, hepatectomy was not performed, but the right hemicolectomy (D2) and insertion of an arterial infusion catheter into the hepatic artery were performed. In addition, all seven peritoneal tumors were resected. After being discharged from hospital, she was treated as an outpatient with the combination chemotherapy of systemic intravenous administration (5-fluorouracil or 5-FU, 2,500 mg/month) and hepatic arterial infusion (5-FU, 1,500 mg/week) for 16 months. Then, she continued to take tegafur uracil (300 mg/day) by mouth for 39 months. The metastatic liver tumors were gradually reduced and resulted in complete response (CR) for 20 months after the operation. She has been in remission for the past 5 years without recurrence. During the treatment, we noticed a complete atrophy that was sustained in the right lobe of the liver to which PTPE was performed. As far as hepatic arterial infusion chemotherapy is concerned, our case study was interesting and effective.

End-to-side portocaval shunting for a small-for-size graft in living donor liver transplantation

In the development of adult-to-adult living donor liver transplantation (LDLT), the small-for-size graft has been associated with poor clinical outcome. Persistent portal hypertension or portal venous overperfusion are considered to be causative factors, and partial diversion of portal flow to systemic circulation may be effective for avoiding injuries that occur in the small-for-size (SFS) graft. Recently, we constructed an end-to-side portocaval shunting using 1 of the portal branches and anastomosed the other branch with the portal vein of the graft in 2 cases of LDLT recipients transplanted with a SFS graft. With the suppression of portal hypertension, as well as sufficient portal flow to the graft, the recipients recovered successfully with favorable graft function. This new and simple technique may be able to be used as a feasible and effective method to attenuate the SFS syndrome.

Radiofrequency ablation therapy for bone metastasis from hepatocellular carcinoma: case report

BACKGROUND

Radiofrequency ablation (RFA) is one of the standard percutaneous therapies for hepatocellular carcinoma (HCC), but RFA has not been applied to treat bone metastasis from HCC.

CASE

A 65-year-old male patient, who underwent hepatectomy for HCC two and a half years previously, complained of pain in his right thigh. Imaging modalities and a needle biopsy revealed metastatic HCC in his right acetabulum. The first RFA therapy was attempted under computed tomography (CT) guidance with 42 Gy radiation therapy. The second RFA therapy was performed for tumor recurrence in his pelvis at 4 years after the first RFA.

CONCLUSION

RFA is a safe, easy, repeatable and effective therapy and should be one of the most important therapeutic modalities for bone metastasis from HCC.

Effectiveness of hydroxyethyl starch (HES) on purification of pancreatic islets

BACKGROUND

The isolation of large-scale and high-quality islets from the pancreas is essential for a successful islet transplantation. We developed a hydroxyethyl starch (HES)-Collins solution as the purification medium and evaluated its usefulness on islet isolation from the pancreas of beagle dogs.

MATERIALS AND METHODS

The pancreas of beagle dog was digested using our original 2-step automated technique. Islets were purified by discontinuous purification method on HES-Collins solution (group 1, n = 10) or Euro-Ficoll solution (group 2, n = 16) with a COBE2991 cell processor. Islet yield and purity, changes in islet number during 3-day cultures, static incubation, perifusion study, and insulin content were examined. In addition, the islets were autotransplanted into the liver via the portal vein.

RESULTS

Although no significant differences were detected, yield and purity were higher in group 1. After 3 days of culture, the islet number decreased less in group 1. Both under static incubation and in the perifusion study, stimulation indices were 4.50 +/- 1.82 and 6.02 +/- 1.05, which were significantly higher than the 2.18 +/- 0.67 and 3.32 +/- 1.46 observed in group 2. Also, insulin content of the islets was significantly higher in group 1 than in group 2. Fasting blood glucose levels were maintained at values below 100 mg/dl for 100 days in group 1 and around 200 mg/dl in group 2.

CONCLUSIONS

The use of HES-Collins solution was associated with an improvement of islet yield and purity. Also, islet viability and function were preserved longer during culture. Accordingly, islet purification using HES-Collins solution might be recommended for clinical islet transplantation.

Endothelial cell senescence in human atherosclerosis: role of telomere in endothelial dysfunction

BACKGROUND

The functional changes associated with cellular senescence may be involved in human aging and age-related vascular disorders. We have shown the important role of telomere and telomerase in vascular cell senescence in vitro. Progressive telomere shortening in vivo has been observed in the regions susceptible to atherosclerosis, implying contributions to atherogenesis. However, whether senescent vascular cells are present in the vasculature and contribute to the pathogenesis of atherosclerosis remains unclear.

METHODS AND RESULTS

Senescence-associated beta-galactosidase (beta-gal) activity was examined in the coronary arteries and the internal mammary arteries retrieved from autopsied individuals who had had ischemic heart diseases. Strong beta-gal stainings were observed in atherosclerotic lesions of the coronary arteries but not in the internal mammary arteries. An immunohistochemical analysis using anti-factor VIII antibody demonstrated that beta-gal stained cells are vascular endothelial cells. To determine whether endothelial cell senescence causes endothelial dysfunction, we induced senescence in human aortic endothelial cells (HAECs) by inhibiting telomere function and examined the expression of intercellular adhesion molecule (ICAM)-1 and endothelial nitric oxide synthase (eNOS) activity. Senescent HAECs exhibited increased ICAM-1 expression and decreased eNOS activity, both of which are alterations implicated in atherogenesis. In contrast, introduction of telomerase catalytic component significantly extended the life span and inhibited the functional alterations associated with senescence in HAECs.

CONCLUSIONS

Vascular endothelial cells with senescence-associated phenotypes are present in human atherosclerotic lesions, and endothelial cell senescence induced by telomere shortening may contribute to atherogenesis.

Direct determination of interfacial magnetic moments with a magnetic phase transition in Co nanoclusters on Au(111)

The spin, in-plane and out-of-plane orbital and magnetic dipole moments of almost purely interfacial Co atoms were directly determined for Au/2-monolayer Co nanoclusters/Au(111) by angle-dependent magnetic circular x-ray dichroism (MCXD) measurements. The field- and temperature-dependent MCXD evidences a ferromagnetic(FM)-to-superparamagnetic phase transition in single-domain clusters with decreasing size. The interfacial moments are remarkably enhanced as compared with bulk values, verifying theoretical predictions. The FM clusters show strong perpendicular magnetic anisotropy, providing promise of applications for nanoscale magnetic bits.

Close correlation between the magnetic moments, lattice distortions, and hybridization in LaMnO3 and La(1-x)Sr(x)MnO3+delta: doping-dependent magnetic circular X-ray dichroism study

The first observation of a magnetic circular x-ray dichroism (MCXD) at the Mn L2,3 core edges in antiferromagnetic LaMnO3 shows canted spin and orbital ( m(orb)) moments arising from lattice distortions. An L2,3-edge MCXD in ferromagnetic metals and insulators, La1-xSr(x)MnO3+delta, reveals that m(orb) of Mn strongly depends on x in the metallic regime but remains unchanged with the metal-to-insulator transition (x approximately 0.16). An O K-edge MCXD, which shows m(orb) of O caused by 2p-3d hybridization, is much larger in the ferromagnetic metal than insulator phases, sharply contrasting with m(orb) of Mn. Our findings indicate a close magnetism-lattice-hybridization coupling.