Role of translocation of pathogen-associated molecular patterns in sepsis

BACKGROUND/AIM

Unlike animals, the incidence of bacterial translocation and its clinical significance remain to be determined in humans, which may be due to the lack of accurate methods to confirm and monitor bacterial translocation. The literature on the consequences of novel insights of bacterial translocation was reviewed.

METHODS

The Medline databases were searched for publications regarding translocation of bacteria as well as pathogen-associated molecular patterns.

RESULTS

Although substantial data support the occurrence of bacterial translocation in humans, the lack of data correlating bacterial translocation with its clinical significance has lead to confusion among physicians. Toll-like receptors have been implicated in the mediation of systemic responses to the relevant pathogen-associated molecular pattern. The gut is a reservoir of pathogen-associated molecular patterns from microbes, and translocation of pathogen-associated molecular patterns other than endotoxin also induces a systemic inflammatory response through toll-like receptors.

CONCLUSIONS

Pathogen-associated molecular patterns translocation may be at least partly responsible for the development of sepsis under conditions in which bacterial translocation may occur. Detection of bacterial DNA in blood and tissues/organs should be useful as a marker of translocation of pathogen-associated molecular patterns and/or bacterial translocation, and should have the predictive value for developing sepsis in surgical patients.

Impact of whole body irradiation and vascular endothelial growth factor-A on increased beta cell mass after bone marrow transplantation in a mouse model of diabetes induced by streptozotocin

AIMS/HYPOTHESIS

Recent studies have shown that bone marrow transplantation reduces hyperglycaemia in a mouse model of diabetes induced by streptozotocin. However, the essential factors for the improvement of hyperglycaemia by bone marrow transplantation have not been fully elucidated. The aim of this study was to search for such factors.

METHODS

We investigated the effect of irradiation to whole body, to abdomen alone or to whole body excluding abdomen, followed by infusion or no infusion of bone marrow cells. We also investigated the effect of bone marrow transplantation on beta cell-specific vascular endothelial growth factor-A gene (Vegfa) knockout mice.

RESULTS

Bone marrow transplantation improved streptozotocin-induced hyperglycaemia and partially restored islet mass. This change was associated with increased islet vascularisation. Among the other methods investigated, low-dose irradiation of the whole body without infusion of bone marrow cells also improved blood glucose level. In streptozotocin-treated beta cell-specific Vegfa knockout mice, which exhibit impaired islet vascularisation, bone marrow transplantation neither improved hyperglycaemia, relative beta cell mass nor islet vascularisation.

CONCLUSION/INTERPRETATION

Our results indicate that whole body irradiation is essential and sufficient for restoration of beta cell mass after streptozotocin treatment independent of infusion of bone marrow cells. Vascular endothelial growth factor-A produced in beta cells is also essential for this phenomenon.

Expression of centromere protein F (CENP-F) associated with higher FDG uptake on PET/CT, detected by cDNA microarray, predicts high-risk patients with primary breast cancer

BACKGROUND

Higher standardized uptake value (SUV) detected by 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) correlates with proliferation of primary breast cancer. The purpose of this study is to identify specific molecules upregulated in primary breast cancers with a high SUV and to examine their clinical significance.

METHODS

We compared mRNA expression profiles between 14 tumors with low SUVs and 24 tumors with high SUVs by cDNA microarray. We identified centromere protein F (CENP-F) and CDC6 were upregulated in tumors with high SUVs. RT-PCR and immunohistochemical analyses were performed to validate these data. Clinical implication of CENP-F and CDC6 was examined for 253 archival breast cancers by the tissue microarray.

RESULTS

The relative ratios of CENP-F and CDC6 expression levels to beta-actin were confirmed to be significantly higher in high SUV tumors than in low SUV tumors (p = 0.027 and 0.025, respectively) by RT-PCR. In immunohistochemical analysis of 47 node-negative tumors, the CENP-F expression was significantly higher in the high SUV tumors (74%) than the low SUV tumors (45%) (p = 0.04), but membranous and cytoplasmic CDC6 expressions did not significantly differ between both groups (p = 0.9 each). By the tissue microarray, CENP-F (HR = 2.94) as well as tumor size (HR = 4.49), nodal positivity (HR = 4.1), and Ki67 (HR = 2.05) showed independent impact on the patients' prognosis.

CONCLUSION

High CENP-F expression, correlated with high SUV, was the prognostic indicators of primary breast cancer. Tumoral SUV levels may serve as a pretherapeutic indicator of aggressiveness of breast cancer.

Helicobacter pylori augments growth of gastric cancers via the lipopolysaccharide-toll-like receptor 4 pathway whereas its lipopolysaccharide attenuates antitumor activities of human mononuclear cells

PURPOSE

Helicobacter pylori is reportedly involved in the development of gastric cancer. We investigated the mechanisms by which H. pylori affects gastric cancer growth and antitumor immunities in the host, focusing on H. pylori-derived lipopolysaccharide (LPS).

EXPERIMENTAL DESIGN

H. pylori and four gastric cancer cell lines (MKN28, MKN45, NUGC3, and KATOIII) were used. We examined the effect of H. pylori or its LPS stimulation on cancer growth and the involvement of the H. pylori LPS-toll-like receptor 4 (TLR4) pathway. We also examined the cytotoxicities of H. pylori/LPS-stimulated human mononuclear cells (MNC) against gastric cancer cells and the effect of H. pylori LPS stimulation on cytokine production by MNC.

RESULTS

H. pylori, as well as its LPS, augmented the growth of gastric cancers, all of which expressed TLR4. Neutralization of TLR4 almost completely abrogated the H. pylori-induced proliferative activity of cancer cells. Escherichia coli LPS also augmented cancer growth via the LPS-TLR4 pathway. However, only H. pylori-derived LPS attenuated the cytotoxicity of MNC against gastric cancer cells. Stimulation with H. pylori/LPS also down-regulated perforin production in cancer cell-cocultured CD56+ natural killer cells. H. pylori LPS induced neither interleukin-12 nor IFN-gamma production by MNC, although E. coli LPS did induce production of both significantly. Nevertheless, interleukin-12 stimulation restored the IFN-gamma-producing capacity of H. pylori LPS-stimulated MNC.

CONCLUSION

H. pylori augmented the growth of gastric cancers via the LPS-TLR4 pathway, whereas it attenuated the antitumor activity and IFN-gamma-mediated cellular immunity of MNC. H. pylori infection might thereby promote proliferation and progression of gastric cancers.

Utility of 18F-fluoro-deoxyglucose emission tomography/computed tomography fusion imaging (18F-FDG PET/CT) in combination with ultrasonography for axillary staging in primary breast cancer

Background

Accurate evaluation of axillary lymph node (ALN) involvement is mandatory before treatment of primary breast cancer. The aim of this study is to compare preoperative diagnostic accuracy between positron emission tomography/computed tomography with ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG PET/CT) and axillary ultrasonography (AUS) for detecting ALN metastasis in patients having operable breast cancer, and to assess the clinical management of axillary ¹⁸F-FDG PET/CT for therapeutic indication of sentinel node biopsy (SNB) and preoperative systemic chemotherapy (PSC).

Methods

One hundred eighty-three patients with primary operable breast cancer were recruited. All patients underwent ¹⁸F-FDG PET/CT and AUS followed by SNB and/or ALN dissection (ALND). Using ¹⁸F-FDG PET/CT, we studied both a visual assessment of ¹⁸F-FDG uptake and standardized uptake value (SUV) for axillary staging.

Results

In a visual assessment of ¹⁸F-FDG PET/CT, the diagnostic accuracy of ALN metastasis was 83% with 58% in sensitivity and 95% in specificity, and when cut-off point of SUV was set at 1.8, sensitivity, specificity, and accuracy were 36, 100, and 79%, respectively. On the other hand, the diagnostic accuracy of AUS was 85% with 54% in sensitivity and 99% in specificity. By the combination of ¹⁸F-FDG PET/CT and AUS to the axilla, the sensitivity, specificity, and accuracy were 64, 94, and 85%, respectively. If either ¹⁸F-FDG PET uptake or AUS was positive in allixa, the probability of axillary metastasis was high; 50% (6 of 12) in ¹⁸F-FDG PET uptake only, 80% (4 of 5) in AUS positive only, and 100% (28 of 28) in dual positive. By the combination of AUS and ¹⁸F-FDG PET/CT, candidates of SNB were more appropriately selected. The axillary ¹⁸F-FDG uptake was correlated with the maximum size and nuclear grade of metastatic foci (p = 0.006 and p = 0.03).

Conclusion

The diagnostic accuracy of ¹⁸F-FDG PET/CT was shown to be nearly equal to ultrasound, and considering their limited sensitivities, the high radiation exposure by ¹⁸F-FDG PET/CT and also costs of the examination, it is likely that AUS will be more cost-effective in detecting massive axillary tumor burden. However, when we cannot judge the axillary staging using AUS alone, metabolic approach of ¹⁸F-FDG PET/CT for axillary staging would enable us a much more confident diagnosis.

Prognostic significance of expression of CCL5/RANTES receptors in patients with gastric cancer

BACKGROUND AND OBJECTIVES

The clinical significance of CCL5 has been reported in several malignancies. In this study, we examined the prognostic impact of serum CCL5 levels and the expression of CCL5 receptors on tumor cells in patients with gastric cancer.

METHODS

Serum CCL5 levels in patients with gastric cancer were measured by enzyme-linked immunoabsorbent assay. Immunohistochemical staining of three chemokine receptors, CCR1, CCR3, and CCR5, which are known as CCL5 receptors, was performed in gastric cancer tissue.

RESULTS

We found that serum CCL5 levels themselves had no impact on survival; however, higher serum CCL5 concentrations were associated with more advanced disease. Eighty-six (41%), 48 (23%), and 60 patients (28%) showed positive expression of CCR1, CCR3, and CCR5, respectively, on gastric cancer cells. Among the patients who underwent curative resection for stages II-IV disease, patients with positive CCR3 expression had significantly lower survival rates compared to those with negative CCR3 expression. Unlike CCR1, positive CCR5 expression was also associated with poorer prognosis. Multivariate analysis revealed that expression of CCR3 and/or CCR5 was an independent prognostic factor.

CONCLUSIONS

Tumor expression of CCR3 and/or CCR5 (receptors for CCL5) is associated with a lower survival rate in patients with gastric cancer.

Gastric cancer cells exploit CD4+ cell-derived CCL5 for their growth and prevention of CD8+ cell-involved tumor elimination

The level of serum CCL5, a C-C chemokine, is reportedly correlated with tumor progression in several cancers. We herein investigated the mechanisms by which CCL5 might contribute to tumor progression in gastric cancer. Serum CCL5 levels significantly correlated with tumor progression and prognosis in patients with gastric cancer. Immunohistochemistry showed that tumor-infiltrating lymphocytes expressed CCL5, while the tumor cells expressed the CCL5 receptors. Fluorescent double staining showed that tumor-infiltrating CD4+ cells rather than CD8+ cells preferentially expressed CCL5. Using gastric cancer cell lines (MKN45, KATO III), we examined CCL5 production by coculturing whole peripheral blood mononuclear cells (PBMCs), CD4+ cells, or CD8+ cells, with tumor cells. CD4+ cells cocultured with tumor cells remarkably enhanced CCL5 production in a direct cell-cell contact manner over other cocultured PBMCs, including CD8+ cells. Gastric cancer cell lines expressed CCL5 receptors and augmented their proliferation in response to CCL5 stimulation. Furthermore, we examined the effect of CCL5-treated cancer cells on the cocultured PBMCs, focusing on the CD4+/CD8+ proportion and apoptosis. Coculture of CCL5-treated gastric cancer cells with PBMCs resulted in a significant decrease in the proportion of CD8+ cells but not CD4+ cells, suggesting Fas-FasL-mediated apoptosis in CD8+ cells. In immunodeficient mice coinjected with KATO III and PBMCs, neutralization of CCL5 significantly suppressed tumor progression, resulting in a favorable outcome. In conclusion, gastric cancer cells might thus induce CD4+ T cells to secrete CCL5 and exploit it for their progression, as well as to aid in the prevention of CD8+ T cell-involved tumor elimination.

305 TRANSGENIC CLONED PIGS EXPRESSING ORANGE FLUORESCENT PROTEIN KUSABIRA-ORANGE

Transgenic (Tg)-cloned pigs expressing fluorescent proteins are very useful in research such as cell or tissue transplantation studies. In this study, we produced Tg-cloned pigs with an orange fluorescent protein, humanized Kusabira-Orange (huKO), and analyzed the characteristics of these pigs. Fetal fibroblast cells transduced with huKO gene by a gene silencing-resistant retroviral vector, pDΔNhuKO (Suzuki et al. 2002 J. Neurochem. 82, 953–960) were used as nuclear donors. Recipient cytoplasts were prepared using oocytes matured in vitro in NCSU23. The nuclear transfer (NT) embryos were transferred into oviducts of estrus-synchronized recipient gilts after culture in PZM-5 for 1 or 2 days. Cloned pigs obtained were analyzed by Southern blotting for the transgene integration. A total of 23 organs and tissues, including brain, eye, internal and reproductive organs, skin, skeletal muscle, and cartilage were examined by fluorescence stereomicroscopy. Cryo- and paraffin-embedded tissue sections were also prepared to examine fluorescence expression. Immunofluorescent staining of brain cryosection and flow cytometry analysis of peripheral blood cells were performed to identify huKO-expressing cells. Transfer of 429 NT embryos into 4 recipients resulted in 18 (4.2%) cloned offspring. Southern blotting analysis of the cloned pigs confirmed transduction of 2 to 17 copies of the huKO gene in each pig. Autopsy was performed in 6 pigs, and orange fluorescence was confirmed in all the tissues and organs examined in each pig. In addition, prominent orange fluorescence was detected in pancreatic islets and renal glomeruli, indicating that these transgenic pigs are ideal for islet cell transplantation studies. Expression of huKO was also detected in neurons, microglia, and astrocytes in the brain, and granulocytes, monocytes, macrophages, lymphocytes, and platelets in the peripheral blood cells, whereas the expression level in red blood cells was lower. Re-cloning was performed using primary culture fibroblast cells established from 2 Tg-cloned pigs. Transfer of 300 re-cloned embryos into 4 recipients resulted in 3 pregnancies. A re-cloned fetus at Day 44 of gestation showed systemic fluorescence. These results demonstrate that the retroviral vector pD?NhuKO is resistant to gene silencing in pigs, that transduction and expression of the huKO gene had no lethal effects on fetal development, and that a Tg-cloned pig expressing orange fluorescence can be produced by NT of fetal fibroblast cells transduced with the huKO gene. This study was supported by PROBRAIN.

Effects of neutrophil elastase inhibitor on progression of acute lung injury following esophagectomy

The purpose of this study was to evaluate the effect of sivelestat sodium hydrate, a selective inhibitor of neutrophil elastase in the systemic inflammatory response, pulmonary function, and the postoperative clinical course following esophagectomy. Patients with hypoxia associated with surgical stress in the intensive care unit (ICU) immediately after an esophagectomy were eligible for this study. The degree of hypoxia was calculated according to the ratio of arterial oxygen tension (PaO(2)) to the fractional concentration of inspired oxygen (FiO(2))-PaO(2)/FiO(2). Patients with PaO(2)/FiO(2) < 300 mmHg were enrolled in this study. Seven patients were treated with sivelestat, and 10 were not so treated. The degree of hypoxia, the criteria for systemic inflammatory response syndrome (SIRS), and the postoperative clinical course were compared between the two groups. The postoperative decreases in the PaO(2)/FiO(2) ratio were significantly suppressed in the sivelestat group (p < 0.05, by analysis of variance, or ANOVA). Furthermore, 9 of the 10 control group patients developed SIRS on postoperative day 2, whereas only 2 of 7 of the sivelestat group patients developed SIRS (p < 0.05). The postoperative increases in the heart rate were significantly suppressed in the sivelestat group (p < 0.05, ANOVA). The postoperative decreases in the platelet counts were significantly suppressed in the sivelestat group (p < 0.05, ANOVA). The duration of mechanical ventilation and the length of ICU stay for the sivelestat group were shorter than that for the control group. We demonstrated that the postoperative decreases in the PaO(2)/FiO(2) ratio following esophagectomy were significantly suppressed in the sivelestat-treated group. This clinical study showed that a neutrophil elastase inhibitor may thus be a potentially useful drug for treating acute lung injury following esophagectomy.

Influence of adding fish oil to parenteral nutrition on gut-associated lymphoid tissue

BACKGROUND

Lack of enteral nutrition reduces gut-associated lymphoid tissue (GALT) mass and function, a mechanism underlying the increased morbidity of infectious complications in severely injured or critically ill patients. Strategies to restore parenteral nutrition (PN)-induced changes of GALT mass and function have been pursued. However, the influences of adding fish oil to PN on gut immunity remain to be clarified.

METHODS

Male Institute of Cancer Research (ICR) mice (n = 50) were randomized to 4 groups: ad libitum chow (chow), fat free PN (fat (-)-PN), PN + fish oil (FO-PN), and PN + safflower oil (SO-PN). The PN groups were given isocaloric and isonitrogenous PN solutions. The FO- and SO-PN groups received 20% of total calories from fat emulsions. After 5 days of feeding, lymphocytes from Peyer's patches (PPs), the intraepithelial space (IE), and the lamina propria (LP) of the entire small intestine were isolated. GALT lymphocyte numbers and phenotypes (CD4+, CD8+, alphabetaTCR+, gammadeltaTCR+, B220+ cells) were determined. Immunoglobulin A (IgA) levels of small intestinal washings were also measured by enzyme-linked immunosorbent assay. Another set of mice (n = 24) was used to determine plasma fatty acid compositions after feeding.

RESULTS

Lymphocyte numbers from PPs and the LP and intestinal IgA levels were significantly lower in the PN groups than in the chow group, with no significant differences between any 2 PN groups. The FO- and SO-PN groups showed moderate recovery of IE cell numbers compared with the fat (-)-PN group. Omega-3 and omega-6 fatty acid levels were increased with fish and safflower oil additions, respectively, compared with the fat (-)-PN group.

CONCLUSIONS

Adding fish oil to PN does not exacerbate PN-induced GALT changes but rather partially reverses these changes, with increased plasma omega-3 fatty acid levels.

Intraluminal Glutamine Administration During Ischemia Worsens Survival After Gut Ischemia-Reperfusion

BACKGROUND

Glutamine (GLN) treatment prior to gut ischemia-reperfusion (I/R) reportedly preserves gut glutathione levels and gut barrier function. We hypothesized that intraluminal GLN during ischemia would also protect against gut I/R.

MATERIAL AND METHODS

After randomization to control and GLN groups, mice were exposed to 75 min (Exp 1) or 50 min (Exp 2 and 3) gut I/R. One mL of 2% GLN solution was injected into the duodenal lumen at the onset of ischemia in the GLN group, whereas controls were given normal saline. In experiment 1, survival was monitored for 120 h (n = 38). In experiment 2, blood, small intestine, and liver samples were collected at 4 h after reperfusion (n = 13). Expressions of CD11a and CD11b on myeloid cells were measured. Reactive oxygen intermediate production by myeloid cells was determined with or without phorbol myristate acetate stimulation. Glutathione levels in the small intestine and liver were also evaluated. In experiment 3, hemodynamic parameters were measured before and after I/R (n = 6).

RESULTS

In experiment 1, survival time in the GLN group was reduced compared with the control group. In experiment 2, GLN increased expression of CD11b and reactive oxygen intermediate with phorbol myristate acetate, compared with controls. There were no significant differences in gut or liver glutathione levels between the two groups. In experiment 3, the GLN group showed a transient but significant reduction in systolic blood pressure after reperfusion compared with the control group.

CONCLUSION

Intraluminal GLN during severe gut ischemia worsens outcomes, possibly by enhancing circulating myeloid cell priming and activation, and by disturbing hemodynamics, without increasing organ glutathione levels.

Absence of cyclooxygenase-2 protein expression is a predictor of tumor regression in rectal cancer treated with preoperative short-term chemoradiotherapy

PURPOSE

Neoadjuvant chemoradiotherapy followed by total mesorectal excision has become the standard of care for patients with locally advanced rectal cancer. This study was designed to determine whether pretreatment cyclooxygenase-2 and p53 protein expression were predictors of histopathologic response in patients with rectal cancer treated with preoperative short-term chemoradiotherapy.

METHODS

Fifty-two patients with low rectal cancer received short-term preoperative chemoradiotherapy (20 Gy given in 5 daily doses of 4 Gy and concurrent administration of Tegafur/Uracil 400 mg/day), followed by total mesorectal excision. Cyclooxygenase-2 and p53 protein expression were measured by immunohistochemistry before and at the time of resection. Tumor regression grading was evaluated according to the criteria by Rodel (Grade 4, complete regression; Grade 3, regression >50 percent; Grade 2, 25-50 percent; Grade 1,<25 percent; and Grade 0, no regression).

RESULTS

Two patients had a pathologic complete response. Good response (Grade 3 + 4) was found in 57.7 percent of the resected specimens. Cyclooxygenase-2 was expressed in 80.8 percent of patients before chemoradiotherapy and in 100 percent after chemoradiotherapy. The rates of good response (Grade 3 + 4) were significantly associated with lack of cyclooxygenase-2 expression before chemoradiotherapy (P = 0.021). However, there was no correlation between p53 protein expression and tumor regression grading.

CONCLUSIONS

Patients with tumor lacking cyclooxygenase-2 expression before chemoradiotherapy are more likely to demonstrate good response to treatment. Cyclooxygenase-2 protein expression may be a marker for response to chemoradiotherapy in patients with rectal cancer.

Analysis of sentinel node involvement in gastric cancer

BACKGROUND & AIMS

Sentinel node navigation surgery (SNNS) is performed for patients with early gastric cancer. Because sentinel nodes (SNs) to gastric cancer exist but they have not been well-described, we attempted to validate the SN concept at the micrometastasis level.

METHODS

For 53 patients who underwent curative gastrectomy for T1/T2 (<4 cm) N0 gastric cancer, SNNS was performed with radioactive tin colloid and/or indocyanine green, and subsequent modified D1 lymphadenectomies were added. Whole formalin-fixed paraffin-embedded tissues of all resected lymph nodes from these patients were cut into 5-mum thick serial step sections at 85-mum intervals, and occult metastases were examined immunohistochemically.

RESULTS

Metastases were detected in 3 (1.5%) of 204 SNs and 3 (0.33%) of 901 non-SNs in pN0 cases and in 18 (46%) of 39 SNs and 3 (1.9%) of 158 non-SNs in pN1 cases. On a patient basis, metastases were detected in 4 (9%) of 46 pN0 patients, 2 (4%) each in SNs and non-SNs, and in 7 pN1 patients, of whom 7 and 4 had SN and non-SN metastases, respectively. The sensitivity, false-negative rate, and accuracy of SN identification by SNNS were 82%, 18%, and 96%, respectively, at the occult metastasis level. However, on the basis of the concept of the sentinel lymphatic station (SLS), which represents all lymphatic stations to which SNs belong, metastases were always limited to the lymph nodes in SLS in the 11 cases with metastases. Non-SN metastases occurred in 3 (60%) of 5 patients with SN metastases >2.0 mm in diameter but not in 4 patients with SN metastases </=2.0 mm in diameter.

CONCLUSIONS

The sentinel node concept held true at the occult metastasis level in 96% of patients with gastric cancer, and the accuracy of SNNS was elevated to 100% by introducing the concept of the sentinel lymphatic station. The size of SN metastasis was a predictive factor for metastasis beyond the sentinel node.

Serum granulysin level as a novel prognostic marker in patients with gastric carcinoma

BACKGROUND

Granulysin is a cytolytic molecule present in human cytotoxic T cells and natural killer cell granules, and plays a key role in the cell-mediated immunity against tumor and infection. However, few studies have estimated serum granulysin concentrations in patients with solid or hematological malignancies.

METHODS

Peripheral blood samples were taken from patients with gastric carcinoma preoperatively and from healthy volunteers. Serum and tumor tissue granulysin concentrations were measured using a granulysin-specific ELISA kit in order to assess its prognostic value.

RESULTS

Both serum and tumor tissue granulysin concentrations were higher in patients with stage II or III gastric cancer and lower in patients with stage IV disease as compared to healthy controls. The low preoperative granulysin levels were associated with more frequent hepatic and peritoneal metastases, and with a poor outcome of the curative gastrectomy.

CONCLUSIONS

Preoperative serum granulysin levels reflect the status of cell-mediated immunity in patients with gastric carcinoma. It has significance as a prognostic determinant following a curative resection.

Interleukin-18 restores immune suppression in patients with nonseptic surgery, but not with sepsis

BACKGROUND

We investigated cellular immune responses, in particular interferon gamma (IFN-gamma) production, by peripheral blood mononuclear cells (PBMCs) in patients with septic and nonseptic surgical stress, focusing on interleukin (IL)-18 and its receptor (IL-18R).

METHODS

Thirty-two patients with alimentary tract carcinoma who underwent elective surgery (OP) and 26 septic patients (SP) with peritonitis were enrolled in this study. Blood was collected on the first postoperative day (POD1), POD5, POD10, and POD15 in the OP group and on the emergency admission in the SP group. Ten healthy volunteers served as controls. PBMCs were cultured in the presence of anti-CD3 antibody or IL-2 and IL-12, with or without additional IL-18 stimulation, to measure IFN-gamma production. IL-18R expression on CD56+ NK (natural killer) cells was evaluated by flow cytometry.

RESULTS

IL-2- and IL-12-induced IFN-gamma production by PBMCs was suppressed significantly in both the OP (POD5) and SP groups compared with that in healthy controls. Interestingly, additional IL-18 stimulation up-regulated IFN-gamma production by PBMCs in the OP group as well as the control group, but not in the SP group. IL-18R expression on CD56+ NK cells was maintained consistently in the OP group as well as the control group, but decreased in the SP group.

CONCLUSIONS

IFN-gamma production induced by cytokines (IL-2 and IL-12) was suppressed in PBMCs from both patients with sepsis and those who had undergone elective surgery. However, IL-18R expression on CD56+ NK cells was different between patients with sepsis and nonseptic surgical stress. Our results suggest that exogenous IL-18 administration may be effective in preventing immune suppression in patients with nonseptic elective surgery.

Proposal for a new definition of true cardia carcinoma

BACKGROUND AND OBJECTIVES

It remains controversial whether cardia carcinoma should be categorized and treated as esophageal cancer or gastric cancer. The purpose of this study was to develop a reasonable definition of cardia carcinoma.

METHODS

Patients with Siewert type II carcinomas were divided into two subgroups: 25 patients with a tumor center within 1 cm of the esophagogastric junction (EGJ) (type IIA) and 22 patients with tumor center 1-2 cm aboral of the EGJ (type IIB). Patients with subcardia carcinomas, 40 with invasion to the EGJ (type III) and 110 without (type IIIe-), were used as controls.

RESULTS

The patients with type IIB carcinomas showed no different characteristics from those with type III or type IIIe- carcinomas, except for the stage of the disease. On the other hand, those with type IIA carcinomas were associated with a higher male/female ratio, higher incidences of elevated appearance, differentiated histology, and mediastinal node metastasis, and a significantly lower survival rate as compared with patients with subcardia carcinomas. Multivariate survival analysis revealed that type IIA is a significant prognostic determinant, but that type IIB is not.

CONCLUSION

Type IIA carcinomas should be treated as true cardia carcinoma; type IIB as subcardia carcinoma. Our results should be confirmed by a prospective study.

Nutritional route affects ERK phosphorylation and cytokine production in hepatic mononuclear cells

OBJECTIVE

To clarify the influence of nutritional route on hepatic immunity in a murine model.

SUMMARY BACKGROUND DATA

Parenteral nutrition is disadvantageous for preventing infectious complications in critically ill and/or severely injured patients as compared with enteral nutrition. To date, lack of enteral nutrition has been demonstrated to impair mucosal immunity, gut barrier function, and the peritoneal defense system. However, influences of nutritional route on hepatic immunity, another important defense system against infection, have not been well studied.

METHODS

Male ICR mice were randomized to 3 groups: ad libitum chow (chow), intravenous (IV)-TPN and intragastric (IG)-TPN groups. The TPN groups were given isocaloric and isonitrogenous TPN solutions. After the mice had been fed for 5 days, hepatic mononuclear cells (MNCs) were isolated. Hepatic MNC numbers and functions (cytokine production, intracellular signaling, and LPS receptor expression) were determined. Moreover, 1.0 x 10 Pseudomonas aeruginosa were delivered by intraportal injection. Survival and histology were examined.

RESULTS

Hepatic MNC numbers were significantly lower in the IV-TPN group than in the chow and IG-TPN groups, without subpopulation changes. As compared with enterally fed mice, cytokine production (TNF-alpha, IFN-gamma, and IL-10) by hepatic MNCs in response to LPS was impaired in parenterally fed mice in association with blunted phosphorylation of ERK1/2, a MAPK. Hepatic MNCs from IV-TPN mice showed decreased expressions of CD14 and TLR4/MD2, as compared with enterally fed mice. Survival times were reduced in the IV-TPN group as compared with the chow and IG-TPN groups.

CONCLUSION

Preservation of hepatic immunity with enteral feeding is important for prevention of infectious complications in severely injured and/or critically ill patients.

[Surveillance after curative resection for colorectal cancer]

Surveillance after curative resection for colorectal cancer is reviewed with special reference to the guidelines for colorectal cancer treatment issued by the Japanese Society for Cancer of the Colon and Rectum. The principal aim of postoperative surveillance in patients with colorectal cancer is to improve survival by early detection of a recurrence while it is still resectable. Meta-analyses from Western countries demonstrated that intensive follow-up after curative surgery improves survival. In Japan, more intensive follow-up programs have been performed routinely than in Western countries. Although the impact of intensive follow-up on survival has not yet been clarified in a large-scale study, unified follow-up programs are suggested in the guidelines, based on the results of a large-scale, retrospective, multicenter study. The relapse rate in patients with Stage II, IIIa, and IIIb colorectal cancer increased rapidly during the first 3 years and gradually during the next 2 years. The relapse rate at 5 years or later was less than 1%. The prognoses of patients who underwent curative resection for relapse were better than those who did not. Periodic follow-up for metachronous multicentric colorectal cancers should be recommended. Further studies will be necessary to validate the efficacy of intensive follow-up.

Squamous cell carcinoma of the breast in the form of an intracystic tumor

Squamous cell carcinoma of the breast is thought to arise through metaplasia of ductal carcinoma cells. We report a case of pure squamous cell carcinoma of the breast with features of intracystic tumor, which was considered to have arisen from metaplastic squamous epithelial cells lining the cyst wall. A 71-year-old woman presented at our hospital with a 40 x 30-mm mass in the lower outer quadrant of the right breast. Mammography revealed a round, high-density mass, which had a mostly regular but partially irregular margin. Ultrasonography demonstrated a solid tumor with an irregular shape protruding into a cystic space, suspicious of intracystic carcinoma. Aspiration cytology confirmed squamous cell carcinoma. A modified radical mastectomy was performed. Histopathologically, the intracystic tumor was a pure squamous cell carcinoma. The epithelial cells lining the inner cyst wall showed mostly squamous metaplasia, and there was continuity between these cells and the squamous cell carcinoma. 13 months later, the patient is free of disease with no adjuvant therapy.

LACK OF ENTERAL NUTRITION BLUNTS EXTRACELLULAR-REGULATED KINASE PHOSPHORYLATION IN GUT-ASSOCIATED LYMPHOID TISSUE

The mitogen-activated protein kinase (MAPK) family (extracellular-regulated kinase [ERK], p38, etc.) of signal transduction proteins includes important intracellular mediators of inflammation, playing critical roles in host defense. Phosphorylations of ERK and p38 are responsible for cell proliferation, cell differentiation, and cell death. We hypothesized that impaired gut-associated lymphoid tissue (GALT) function in the absence of enteral nutrition is associated with reduced MAPK phosphorylation in GALT cells. Fifty-three male Institute of Cancer Research mice were randomized into 3 groups; ad libitum chow, intragastric (i.g.)-TPN, and intravenous (i.v.)-TPN. TPN groups were administered a standard TPN solution. After 5 days of feeding, lymphocytes from Peyer patches (PPs), the lamina propria (LP) cells, and intraepithelial (IE) spaces in the small intestine were isolated. GALT lymphocyte numbers were determined. The lymphocytes were incubated with or without 50 ng/mL of phorbol myristate acetate (PMA) for 15 min, and phosphorylated ERK (p-ERK) and p38 (p-p38) levels were determined using laser scanning cytometry. In PP (GALT inductive site) lymphocytes, p-ERK was increased after PMA in all three groups. However, ERK phosphorylation in GALT effector sites (IE and LP) was enhanced only in the enteral groups. p38 phosphorylation was not increased in any GALT sites, in any of the three groups, in response to PMA. In another set of mice (n = 33), in vitro LP lymphocyte proliferation was assessed with BrdU with or without PMA. Cell proliferation was increased or maintained at high level with PMA in the i.g.-TPN and chow group, but remained low in the i.v.-TPN group. In conclusion, lack of enteral feeding blunts ERK activation and cell proliferation in response to PMA stimulation in GALT effector sites, which may be an important mechanism underlying reduced GALT function. The influence of nutrition on GALT p38 phosphorylation must be assessed with other types and dosages of stimulants.

Extramural cancer deposits without nodal structure in colorectal cancer: optimal categorization for prognostic staging

To establish an optimal categorization of cancer deposits without lymph node structure (extranodal cancer deposits [EX]) in a prognostic staging system, we analyzed 1,027 cases in which patients underwent potentially curative surgery for advanced colorectal adenocarcinoma. EX was classified as vascular invasion-type (VAS) or non-VAS.A total of 512 foci of EX were identified in 205 patients (20.0%), with VAS and non-VAS found in 68 and 182 patients, respectively. The hazard ratio for patients with nodal involvement was 3.6 and for patients with VAS and non-VAS, 2.5 and 4.7, respectively. Based on multivariate analysis of these 3 parameters, only nodal involvement and non-VAS were significant prognosticators. By using the Akaike information criterion, N staging was capable of predicting survival outcome with the highest accuracy when both nodal involvement and non-VAS were treated together as an N factor and VAS was treated as a T factor ("new categorization"). The clinical significance of the TNM grading system for colorectal cancer would be enhanced if we treat EX as a new categorization.

Successful treatment of malignant pericardial effusion, using weekly paclitaxel, in a patient with breast cancer

We report a case of metastatic breast cancer with pericardial effusion that was successfully treated with weekly paclitaxel. A 46-year-old woman underwent modified radical mastectomy in April 1997 and was readmitted to the hospital for dyspnea in March 2002. A diagnosis of cardiac tamponade due to breast cancer relapse was made, and the patient was treated with weekly paclitaxel (80 mg/m2) and insertion of a drainage catheter. This treatment was effective in preventing reaccumulation of the pericardial effusion until her death. The concentration of paclitaxel in the cardiac effusion was 45 ng/ml at 3 h, 15 ng/ml at 12 h, and less than 10 ng/ml at 24 h after paclitaxel infusion, indicating good transportation of the drug from the blood to the pericardial effusion. These findings suggest that weekly intravenous infusion of paclitaxel could be effective for the treatment of patients with malignant pericardial effusion.

Potential prognostic benefit of lateral pelvic node dissection for rectal cancer located below the peritoneal reflection

OBJECTIVE

To identify the parameters related to the effective selection of patients who could receive prognostic benefit from lateral pelvic node dissection.

BACKGROUND

Accurate preoperative diagnosis of lateral nodal involvement (LNI) remains difficult, and the indications for lateral lymph node dissection have been controversial.

PATIENTS AND METHODS

A total of 244 consecutive patients who underwent potentially curative surgery with lateral dissection for advanced lower rectal cancer (1985-2000) were reviewed. Patients were stratified into groups based on various parameters, and the therapeutic value index for survival benefit was compared among groups. The therapeutic index of lateral dissection was calculated by multiplying the frequency of metastasis to the lateral area and the cancer-related 5-year survival rate of patients with metastasis to the lateral area, irrespective of metastasis to other areas (mesorectal, superior rectal artery [SRA], and inferior mesenteric artery [IMA] areas).

RESULTS

LNI was observed in 41 patients (17%); and 88% of them had nodal involvement in the region along the internal iliac/pudendal artery or in the obturator region ("vulnerable field"). The cancer-related 5-year survival rate among the patients with LNI was 42%; the therapeutic index for lateral dissection was calculated as 7.0 patients, which was much higher than that of lymphadenectomy of the SRA area (1.6 patients) and the IMA area (0.4 patients), and almost comparable to that of lymphadenectomy of the upward mesorectal area (6.9 patients). Although it was possible to select groups at high and low risk for LNI based on several parameters related to tumor aggressiveness, such as tumor differentiation in biopsy specimens, the therapeutic value index was not significantly different between these groups. Unlike these parameters, the diameter of the largest lymph node in the "vulnerable field," which was positively correlated with the rate of LNI but irrelevant to the prognosis, was able to successfully stratify patients by therapeutic index.

CONCLUSIONS

Advanced lower rectal cancer patients having LNI in the lateral pelvic area are likely to receive prognostic benefit from lymphadenectomy. The most efficient means of determining the effectiveness of lateral dissection preoperatively is to estimate the nodal diameter in the "vulnerable" lateral regions by diagnostic imaging.

Characteristics of recurrence and surveillance tools after curative resection for colorectal cancer: A multicenter study

BACKGROUND

The aim of this study was to clarify the characteristics of recurrence and the effectiveness of surveillance tools after curative resection for colorectal cancer.

METHODS

We enrolled 5230 consecutive patients (stage I, 1367; stage II, 1912; stage III, 1951) who underwent curative resection at 14 hospitals from 1991 to 1996. All patients were followed up intensively, and their outcomes were investigated retrospectively.

RESULTS

Of the 5230 patients, 906 developed recurrence. The recurrence rates of stage I, II, and III cancers were 3.7%, 13.3%, and 30.8%, respectively (P < .0001). The curves of the cumulative appearance rate of recurrence in stage II and III patients showed a rapid increase for the first 3 years. Recurrence after 5 years was less than 1% in each stage. Clinical visits combined with measurements of tumor markers detected the majority of recurrences except in the case of lung metastasis. In contrast, 43.4% of hepatic recurrences were detected by liver imaging, and 48.4% of pulmonary recurrences were noted by chest x-ray. The 5-year survival rates after primary colorectal surgery in patients who underwent resection for recurrence were better than in those without resection: 55% vs 11% in hepatic recurrence, 68% vs 13% in pulmonary recurrence, and 48% vs 22% in local recurrence (all P < .001).

CONCLUSION

It is useful to take these characteristics of recurrence into account in the management of patients after curative resection for colorectal cancer and in the setting of clinical trial for follow-up after curative resection for colorectal cancer.

Amelioration of glucose tolerance by hepatic inhibition of nuclear factor kappaB in db/db mice

AIMS/HYPOTHESIS

Recent studies have identified the involvement of inhibitor IkappaB kinase (IKK) in the pathogenesis of insulin resistance. To investigate the mechanism involved, we examined the role of nuclear factor kappaB (NF-kappaB), the distal target of IKK, in hepatic glucose metabolism.

METHODS

To inhibit NF-kappaB activity, db/db mice were infected with adenovirus expressing the IkappaBalpha super-repressor.

RESULTS

The IkappaBalpha super-repressor adenovirus infection caused a moderate reduction of NF-kappaB activity in liver. The treatment was associated with improved glucose tolerance, reduction in the serum insulin level, and increased hepatic triacylglycerol and glycogen contents, but had no effect on insulin-stimulated phosphorylation of Akt. On the other hand, quantification of mRNA in the liver revealed marked reduction of expression of gluconeogenic genes, such as those encoding phosphoenolpyruvate carboxykinase (PEPCK) and glucose-6-phosphatase, concurrent with reduced expression of gene encoding peroxisome proliferator-activated receptor gamma coactivator-1alpha (PPARGC1A, also known as PGC-1alpha). Furthermore, the production of super-repressor IkappaBalpha suppressed the increase in blood glucose level after pyruvate injection.

CONCLUSIONS/INTERPRETATION

Our results indicate that moderate inhibition of NF-kappaB improved glucose tolerance through decreased gluconeogenesis associated with reduced PGC-1alpha gene expression in db/db mice, and suggest that inhibition of NF-kappaB activity in liver is a potentially suitable strategy for the normalisation of blood glucose concentration in type 2 diabetes.

Mucinous carcinoma of the duodenum associated with hereditary nonpolyposis colorectal cancer: report of a case

We herein report a rare case of primary mucinous carcinoma of the duodenum associated with hereditary nonpolyposis colorectal cancer (HNPCC). A 50-year-old man known to have HNPCC based on the Amsterdam criteria I was admitted because of the presence of a duodenal tumor. Duodenoscopy revealed an ulcerated tumor in the posterior wall of the second portion of the duodenum and the malignancy was confirmed by a biopsy. He underwent a pylorus-preserving pancreaticoduodenectomy with a regional lymph node dissection. The histological diagnosis was mucinous carcinoma of the duodenum with lymph node metastasis. High-frequency microsatellite instability (MSI-H) was identified in both the colon and a duodenal specimen based on a microsatellite assay. A germline mutation in the hMSH2 gene was also identified. Even though extracolonic malignancies are associated with HNPCC, duodenal cancer is nevertheless very rare, and only two cases have been reported over the past 20 years. The present case is therefore only the third such case and the patient is herein described with a brief review of the literature.

Influences of long-term antibiotic administration on Peyer's patch lymphocytes and mucosal immunoglobulin A levels in a mouse model

BACKGROUND

Long-term antibiotic administration is sometimes necessary to control bacterial infections during the perioperative period. However, antibiotic administration may alter gut bacterial flora, possibly impairing gut mucosal immunity. We hypothesized that 1 week of subcutaneous (SC) antibiotic injections would affect Peyer's patch (PP) lymphocyte numbers and phenotypes, as well as mucosal immunoglobulin A (IgA) levels.

METHODS

Sixty-one male Institute of Cancer Research mice were randomized to CMZ (cefmetazole 100 mg/kg, administered SC twice a day), IPM (imipenem/cilastatin 50 mg/kg x 2), and control (saline 0.1 mL x 2) groups. After 7 days of treatment, the mice were killed and their small intestines removed. Bacterial numbers in the small intestine were determined using sheep blood agar plates under aerobic conditions (n = 21). PP lymphocytes were isolated to determine cell numbers and phenotypes (CD4, CD8, alphabetaTCR, gammadeltaTCR, B220; n = 40). IgA levels in the small intestinal and bronchoalveolar washings were also measured with ELISA.

RESULTS

Antibiotic administration decreased both bacterial number and the PP cell yield compared with the control group. There were no significant differences in either phenotype percentages or IgA levels at any mucosal sites among the 3 groups.

CONCLUSIONS

Long-term antibiotic treatment reduces PP cell numbers while decreasing bacterial numbers in the small intestine. It may be important to recognize changes in gut mucosal immunity during long-term antibiotic administration.

Antireflux contrivance in jejunal pouch reconstruction after total and proximal gastrectomies

BACKGROUND/AIM

In the reconstruction after gastrectomy, a jejunal pouch may be inferior as a gastric substitute to an isoperistaltic jejunum in terms of preventing reflux. We have developed an antireflux contrivance.

METHODS

A jejunal pouch was made by side-to-side anastomosis of both limbs of the jejunum folded into an inverted U, leaving a bridge of the jejunum 15 cm long at the top of the jejunal pouch (apical bridge). The apical bridge is cut near its oral end, and esophagojejunostomy is done, leaving the isoperistaltic jejunum 6-8 cm long positioned between esophagus and jejunal pouch.

RESULTS

This antireflux contrivance was performed in 37 patients undergoing total gastrectomy and in 22 patients undergoing proximal gastrectomy. There were no operative deaths in this series. Neither anastomotic bleeding nor anastomotic leakage were observed. In a questionnaire survey, 5 patients answered that they had had heartburn twice a week or more often, but the answer was not repeated by any patient. On endoscopic examination, all patients but 1 had normal findings for the esophagus. Mild esophagitis was observed in 1 patient.

CONCLUSION

The antireflux contrivance reported here can be easily, safely, and uniformly done, and it is a useful technique.

A critical role of CpG motifs in a murine peritonitis model by their binding to highly expressed toll-like receptor-9 on liver NKT cells

BACKGROUND

Toll-like receptor (TLR)-9 plays a critical role in the recognition of the CpG motifs, which is frequently observed in bacterial DNA. To date, there have not been any reports regarding the role of bacterial DNA in the systemic circulation on the development of sepsis.

METHODS

We examined the expression of TLR-9 in the liver and spleen in a murine peritonitis model (CLP mice). We also measured the cytokine response of mononuclear cells (MNCs) from normal and CLP mice to CpG oligodeoxynucleotides (ODN) in vitro and in vivo.

RESULTS

TLR-9 expression on F4/80(+) and NK1.1(+)CD3epsilon(+) cells in the liver of CLP mice was elevated compared to sham-operated mice. With regard to cytokine production, we found that CpG ODN markedly stimulated the production of inflammatory cytokines by murine macrophages and liver MNCs. The intravenous injection of CpG ODN in mice that underwent CLP 12h earlier led to their increased cytokine production and their increased mortality. In addition, the depletion of NK/NKT cells contributed to improve their survival rate.

CONCLUSIONS

Our results suggest that, in patients with overwhelming bacterial infection, bacterial DNA may induce liver toxicity that is mediated by liver NKT cells and macrophages that express high levels of TLR-9.

Neuronal specificity of alpha-synuclein toxicity and effect of Parkin co-expression in primates

Recombinant adeno-associated viral (rAAV) vector-mediated overexpression of alpha-synuclein (alphaSyn) protein has been shown to cause neurodegeneration of the nigrostriatal dopaminergic pathway in rodents and primates. Using serotype-2 rAAV vectors, we recently reported the protective effect of Parkin on alphaSyn-induced nigral dopaminergic neurodegeneration in a rat model. Here we investigated the neuronal specificity of alphaSyn toxicity and the effect of Parkin co-expression in a primate model. We used another serotype (type-1) of AAV vector that was confirmed to deliver genes of interest anterogradely and retrogradely to neurons in rats. The serotype-1 rAAV (rAAV1) carrying alphaSyn cDNA (rAAV1-alphaSyn), and a cocktail of rAAV1-alphaSyn and rAAV1 carrying parkin cDNA (rAAV1-parkin) were unilaterally injected into the striatum of macaque monkeys, resulting in protein expression in striatonigral GABAergic and nigrostriatal dopaminergic neurons. Injection of rAAV1-alphaSyn alone decreased tyrosine hydroxylase immunoreactivity in the striatum compared with the contralateral side injected with a cocktail of rAAV1-alphaSyn and rAAV1-parkin. Immunostaining of striatonigral GABAergic neurons was similar on both sides. Overexpression of Parkin in GABAergic neurons was associated with less accumulation of alphaSyn protein and/or phosphorylation at Ser129 residue. Our results suggest that the toxicity of accumulated alphaSyn is not induced in non-dopaminergic neurons and that the alphaSyn-ablating effect of Parkin is exerted in virtually all neurons in primates.

Indication and benefit of pelvic sidewall dissection for rectal cancer

PURPOSE

This study was designed to clarify indication and benefit of pelvic sidewall dissection for rectal cancer.

METHODS

The retrospective, multicenter study collected the data of rectal cancer patients who underwent surgery between 1991 and 1998 and were prospectively followed.

RESULTS

Of 1,977 patients with rectal cancers, 930 underwent pelvic sidewall dissection without adjuvant radiotherapy. Positive lateral lymph nodes were found in 129. Multivariate analysis disclosed a significantly increased incidence of positive lateral lymph nodes in female gender, lower rectal cancers, non-well-differentiated adenocarcinoma, tumor size of > or =4 cm and T3-T4. The five-year survival rate for 1,977 patients was 79.7 percent. The survival of patients with positive lateral lymph nodes was significantly worse than that of Stage III patients with negative lateral lymph nodes (45.8 vs. 71.2 percent, P<0.0001). Multivariate analysis showed significantly worse prognosis in male gender, pelvic sidewall dissection, lower rectal cancers, T3-T4, perirectal lymph node metastasis, and positive lateral lymph nodes. During the median follow-up time of 57 months, recurrence developed in 19.7 percent: 17 percent in negative and 58.1 percent in positive lateral lymph nodes (P<0.0001). Local recurrence was found in 8 percent: 6.8 percent in negative and 25.6 percent in positive lateral lymph nodes (P<0.0001). Multivariate analysis disclosed that lower rectal cancers, non-well-differentiated adenocarcinoma, T3-T4, perirectal lymph node metastasis, and positive lateral lymph nodes were significantly associated with an increased local recurrence.

CONCLUSIONS

Positive lateral lymph node was the strongest predictor in both survival and local recurrence. Pelvic sidewall dissection may be indicated for patients with T3-T4 lower rectal cancers because of the greater probability of positive lateral lymph nodes.

Preoperative Chemoradiotherapy for Esophageal Cancer Enhances the Postoperative Systemic Inflammatory Response*

BACKGROUND

Chemoradiotherapy (CRT) has been established to improve the long-term survival in patients with esophageal carcinoma. However, little is known about whether preoperative CRT may affect the postoperative systemic response.

METHODS

We investigated the postoperative clinical course in terms of the systemic inflammatory response syndrome (SIRS) in patients with preoperative CRT (CRT group) and surgery alone (SA group).

RESULTS

Both the postoperative heart and respiratory rate in the CRT group were significantly higher than in the SA group. The duration and incidence of SIRS, as well as the number of positive criteria for SIRS, were significantly greater than those in the SA group. There was no difference in the postoperative morbidity and mortality between the two groups.

CONCLUSIONS

Preoperative CRT was found to significantly enhance the postoperative SIRS, thus suggesting its potentially higher risk of complications.

Intersphincteric resection in patients with very low rectal cancer: a review of the Japanese experience

PURPOSE

This study was designed to evaluate the feasibility and oncologic and functional outcomes of intersphincteric resection for very low rectal cancer.

METHODS

A feasibility study was performed using 213 specimens from abdominoperineal resections of rectal cancer. Oncologic and functional outcomes were investigated in 228 patients with rectal cancer located <5 cm from the anal verge who underwent intersphincteric resection at seven institutions in Japan between 1995 and 2004.

RESULTS

Curative operations were accomplished by intersphincteric resection in 86 percent of patients who underwent abdominoperineal resection. Complete microscopic curative surgery was achieved by intersphincteric resection in 225 of 228 patients. Morbidity was 24 percent, and mortality was 0.4 percent. During the median observation time of 41 months, rate of local recurrence was 5.8 percent at three years, and five-year overall and disease-free survival rates were 91.9 percent and 83.2 percent, respectively. In 181 patients who received stoma closure, 68 percent displayed good continence, and only 7 percent showed worsened continence at 24 months after stoma closure. Patients with total intersphincteric resection displayed significantly worse continence than patients with partial or subtotal resection.

CONCLUSIONS

Curability with intersphincteric resection was verified histologically, and acceptable oncologic and functional outcomes were obtained by using these procedures in patients with very low rectal cancer. However, information on potential functional adverse effects after intersphincteric resection should be provided to patients preoperatively.

Maturation of murine bone marrow-derived dendritic cells with poly(I:C) produces altered TLR-9 expression and response to CpG DNA

Although poly(I:C) and LPS induced differential dendritic cell (DC) cytokine profiles and toll-like receptor (TLR) expression, all were capable of causing phenotypic and functional DC maturation. Both LPS and poly(I:C) downregulated TLR-4/MD-2 expression on DCs. Although poly(I:C) highly upregulated their cell surface TLR-9 expression, LPS upregulated the intracellular TLR-9 expression. LPS-treated DCs could not produce IL-12p70 in response to subsequent both LPS- and CpG DNA-stimulation. On the other hand, poly(I:C)-treated DCs retained to produce IL-12p70 by subsequent CpG DNA-stimulation, while subsequent LPS-stimulation did not induce IL-12p70 production. Chloroquine, inhibitor of endosomal maturation, completely inhibited cytokine production of LPS-treated DCs as well as unstimulated control in response to subsequent CpG DNA-stimulation, while it failed to delete the IL-12p40 and IL-10 production in poly(I:C)-treated DCs. These data suggest that poly(I:C) may induce a novel DC phenotype that preserves the capacity of cytokine production to subsequent CpG DNA-stimulation.

Differential prognostic significance of morphologic invasive markers in colorectal cancer: tumor budding and cytoplasmic podia

PURPOSE

In colorectal cancer, the presence of cytoplasmic podia around tumor budding foci may be a morphologic marker for an activated budding phenotype that is associated with cell motility. In this study, we have investigated the prognostic significance of cytoplasmic podia.

METHODS

A total of 136 pT3 colorectal cancers were classified according to extent of budding and cytoplasmic podia as identified by immunostaining for cytokeratin. The prognostic significance of budding and cytoplasmic podia was then assessed.

RESULTS

The overall survival curves between the groups with high-grade and low-grade cytoplasmic podia were different (5-year survival rates were 60.5 and 83.8 percent respectively, P = 0.0003). Similar results were shown for tumor budding (59.8 and 87.7 percent, P < 0.0001). Multivariate analysis showed that the grades of cytoplasmic podia (hazards ratio, 2.4; P = 0.012) and budding (hazards ratio, 2.3; P = 0.024) were independent prognostic factors. Additionally, among colorectal cancers with high-grade budding, the grade of cytoplasmic podia was selected as an independent prognostic factor (hazards ratio, 2.4; P = 0.042).

CONCLUSIONS

Cytoplasmic podia and budding are related but independent pathologic predictive markers in patients with resected pT3 colorectal cancer.

Disinhibition of somatosensory evoked potential recovery in alcoholics

The pathogenesis of cognitive impairment in alcoholics remains unclear. Previous studies suggested that diffuse white matter atrophy is associated with cognitive impairment in alcoholics. To elucidate this issue, the present study evaluated alcoholics with cognitive impairment using the somatosensory evoked potential (SEP) recovery method, which is suitable for detecting subtle dysfunction at the cortical level. Subjects comprised 12 alcoholics with mild cognitive impairment [Mild group: Mini Mental State Examination Score (MMSE), > or =24; mean, 27.9 +/- 1.6], 12 alcoholics with moderate to severe cognitive impairment (Moderate group: MMSE score, < 24; mean, 21.0 +/- 2.5) and 12 normal subjects (Control group). SEP was recorded from the hand sensory area contralateral to the median nerve stimulated at the wrist. Single-pulse or paired-pulse stimuli at various interstimulus intervals (10-300 ms) were administered. Recovery functions of N9 (a peripheral nerve component), N20, N20-P25 and P25-N33 (cortical components) were studied. N20 recovery curves of both alcoholic groups were less suppressive than those of Controls, and P25-N33 recovery curves of the Moderate group were more excitatory than those of the Mild or Control groups. A disinhibited recovery pattern of N20 indicates subcortical dysfunction, and a disinhibited pattern of P25-N33 would be induced by cortical dysfunction. Therefore, subcortical dysfunction indicated by an abnormal N20 recovery pattern may contribute to the early cognitive impairment of alcoholics, whilst the cortical dysfunction indicated by an abnormal P25-N33 recovery pattern may contribute to the later cognitive impairment of alcoholics.