Endoscopic submucosal dissection allows less-invasive curative resection for gastric tube cancer after esophagectomy - a case series

Detection of early gastric tube cancers (GTCs) has increased with more detailed surveillance endoscopy using indigo carmine dye following esophagectomy. This retrospective study clarified the clinicopathological features and application of endoscopic submucosal dissection (ESD) for GTCs. Data collected for eight GTCs treated by ESD included clinical and pathological features and outcomes following ESD. Overall, eight GTCs were identified in seven (6.3 %) of 112 patients who underwent esophagectomy and gastric tube reconstruction. Almost all lesions were macroscopically type 0-IIa with mucosal to submucosal invasion, and seven GTCs were successfully resected en bloc by ESD. Submucosal invasion to > 500 microm was observed in one case with associated delayed perforation that was treated conservatively. No local recurrences of GTCs were observed. Detailed surveillance endoscopy using indigo carmine dye appears useful for diagnosing early-stage GTC. Furthermore ESD represents a feasible alternative to conventional endoscopic mucosal resection as a minimally invasive therapy for early-stage GTC.

Expression profile of hepatic drug transporters in patients with hepatocellular carcinoma

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Background: Hepatocellular carcinoma (HCC) does not respond sufficiently to chemotherapy. It has been demonstrated that several transporters can cause drug resistance in tumor cells. In human liver, various drug transporters are expressed and play pivotal roles in hepatic uptake and excretion of drugs. In HCC, the expression profile of hepatic drug transporters may be altered due to pathophysiological changes. However, limited data are available on their expression and regulation in HCC tissues. The aims of this study were to determine the expression levels of hepatic drug transporters in HCC patients and to identify transporter specifically regulated in HCC tissues. Methods: The mRNA expression levels of 17 drug transporters, including 9 solute carrier (SLC) transporters (OAT2, OAT7, OATP1B1, OATP1B3, OATP2B1, OCT1, OCTN2, MATE1 and PEPT1) and 8 ATP-binding cassette (ABC) transporters (R1, MRP1–6 and BCRP), were determined by real-time RT-PCR in cancerous and non-cancerous liver tissues from 57 patients with HCC. Protein expression level was evaluated by Western blot analysis. In addition, DNA methylation status in promoter region of transporter gene was analyzed using bisulfite sequencing. Results: The mRNA expression levels of 11 transporters (OAT7, OCTN2, MATE1, PEPT1, R1, MRP1–6) were significantly increased (1.45 to 4.74-fold, p<0.05) in HCC tissues compared with non-cancerous liver tissues, whereas only OCT1 mRNA was significantly decreased (0.61-fold, p=0.0004). Notably, MRP4 mRNA showed the highest increase, which was consistent with the marked augmentation in the protein level. The frequency of methylation in MRP4 promoter region was comparable between HCC and non-cancerous liver tissues, suggesting other mechanisms than DNA methylation for MRP4 up-regulation. Interestingly, the mRNA expression levels of MRP4 did not change with the differentiation of HCC. Conclusions: It was revealed that most of the hepatic drug transporters were elevated in HCC tissues. Furthermore, we first identified that MRP4 showed remarkable increase in protein as well as mRNA expression levels. These findings suggest that MRP4 is a novel candidate for diagnostic marker and a target molecule to reverse multidrug resistance in chemotherapy for HCC.

No significant financial relationships to disclose.

Phase II study of combination therapy with docetaxel, cisplatin, and S-1 (DCS) for advanced gastric cancer: (KDOG 0601)

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Background: Our previous phase I study (Oncology 2008, 75:1–7) provided evidence that combination chemotherapy with docetaxel, cisplatin, and S-1 (DCS) is effective and well tolerated in patients with advanced gastric cancer. The present multicenter phase II study was conducted to confirm the efficacy and toxicity of DCS in advanced gastric cancer. Methods: Eligibility criteria included a histologically proved diagnosis of gastric adenocarcinoma with at least one measurable metastatic lesion, no previous treatment for gastric cancer except for surgery, an ECOG performance status of 0 to 2, and adequate organ function. Docetaxel (40 mg/m2) and cisplatin (70–60 mg/m2) were given intravenously on day 1, and S-1 was given orally at a dose of 40 mg/m2 twice daily from days 1 to day 14 of a 28-day cycle. Patients received a maximum of 6 cycles. Subsequently, patients were given repeated cycles of S-1 plus docetaxel (DS). The primary endpoint was the objective response rate. Results: 59 patients (47 men, 12 women) were enrolled. The median age was 62 (range: 35–75) years. PS 0/1/2 was 40/18/1. The median number of treatment cycles was 7 (DCS 6+DS 1: range, 1–20). Because myeloid suppression and renal dysfunction developed during the study, we lowered the recommended dose of cisplatin from 70 mg/m2 to 60 mg/m2. The dose of cisplatin was 70 mg/m2 in 19 patients and 60 mg/m2 in 40. The overall response rate was 81.3% (48/59; 95% CI, 80.7–91.2). The response rates with cisplatin 70 mg/m2 and 60 mg/m2 were 78.9% (95% CI, 60.5–97.2) and 82.5% (95% CI, 70.7–94.2), respectively. Tumor down-staging was achieved in 9 (18.7%) of the 48 patients who responded to treatment. The median survival time and median progression-free survival were not reached. Grade 3 or 4 major toxicity comprised leukopenia (44.0%), neutropenia (72.8%), anemia (15.2%), febrile neutropenia (13.5%), anorexia (6.7%), nausea (5.1%), vomiting (5.1%), fatigue (1.6%), and diarrhea (5.1%). There was one treatment-related death caused by the perforation of the primary tumor. This patient refused surgery. Conclusions: DCS was a well-tolerated regimen with a high response rate in patients with advanced gastric cancer. Cisplatin at a dose of 60 mg/m2 was considered adequately effective.

No significant financial relationships to disclose.

Computational schemes for the ground-state pair density

We reconfirm the performance of the initial scheme for calculating the ground-state pair density (Higuchi and Higuchi 2007 Physica B 387 117, 2008 Phys. Rev. B 78 125101) by using the alternative approximation of the correlating kinetic energy functional. It is shown that about 20% of the correlation energy can be reproduced by the initial scheme, irrespective of the approximate form of the correlating kinetic energy functional. On the basis of the initial scheme, various kinds of schemes that go beyond the initial one can be developed. We illustrate two kinds of computational schemes.

Long-term efficacy of Helicobacter pylori eradication in patients with idiopathic thrombocytopenic purpura: 7-year follow-up prospective study

Helicobacter pylori eradication is useful for improvement of a half of patients with idiopathic thrombocytopenic purpura (ITP), but its long-term therapeutic efficacy has not been elucidated. We investigated the long-term efficacy of H. pylori eradication in 30 cases with ITP that were included in our previous study regarding the association between H. pylori infection and ITP. Twenty-one cases were positive and nine cases were negative for H. pylori infection. H. pylori eradication therapy including secondary regimen was successful in 20 cases, half (responder) of whom showed ITP remission 1 month later. Nine responders could be followed up for a long time and did not show re-infection of H. pylori. Eight of nine needed no medication except for eradication therapy. Another case remained in remission for 1 year but thereafter needed a steroid therapy due to the recurrence. Eight nonresponders could be followed up for a long time. All these cases showed a bad clinical course even though they received the other post-treatments including steroid therapy. Three of nine H. pylori-negative cases underwent eradication therapy after obtaining the written informed consent, but none of them showed improvement. Of these three cases, two cases could be followed up. Only one case remained a remission although receiving corticosteroid as a post-treatment. Conditions of H. pylori-negative ITP cases were usually unstable for a long time. H. pylori eradication has a short-term efficacy for about half of H. pylori-positive ITP patients, and the responders to the eradication therapy may receive a long-term clinical benefit without other therapies.

A novel rat model to determine interaction between reflux oesophagitis and bronchial asthma

BACKGROUND

Several studies have shown a strong association between reflux oesophagitis (RO) and bronchial asthma (BA). The precise mechanisms of interaction between RO and BA are uncertain, possibly due to lack of animal models.

AIMS

We established a novel rat model and examined pathogenic interaction of RO and BA.

METHODS

RO and BA were induced in Brown-Norway rats by ligating the transitional region between the forestomach and the glandular portion and wrapping the duodenum near the pylorus, and by ovalbumin (OVA) sensitisation and challenge with OVA aerosol. Rats were divided into four groups: control, RO, BA, and RO+BA. OVA-induced airway inflammation was assessed by the number of infiltrating cells and cytokine levels in bronchoalveolar lavage fluid (BALF). Oesophageal lesion index, histology and expression of cytokine mRNA, as determined by real-time RT-PCR, were also examined.

RESULTS

Significant increases in the number of cells, especially eosinophils, and IL13 but not IFN-gamma concentration in BALF were observed in the RO+BA group compared with the BA group. These enhancements of OVA-induced airway inflammation were prevented by treatment with rabeprazole. Although the oesophagitis lesion index in the RO+BA group did not differ from that in the RO group, eosinophilic infiltration in the oesophageal submucosa and levels of mRNA expression of cytokines such as IL5, IL10, IL13, and RANTES were significantly increased.

CONCLUSION

We established a novel rat model of RO and BA, and found significant interactions of the two diseases. This model thus appears to be useful for examining the association between gastro-oesophageal reflux disease and bronchial asthma.

Accuracy of an interferon-gamma release assay to detect active pulmonary and extra-pulmonary tuberculosis

OBJECTIVE

To examine the performance of an interferon-gamma (IFN-gamma) release assay (QuantiFERON-TB 2G assay [QFT-G]) to detect Mycobacterium tuberculosis infection in a Japanese general hospital, for the diagnosis of active pulmonary tuberculosis (PTB) and extra-pulmonary tuberculosis (EPTB).

DESIGN

We prospectively examined the performance of QFT-G in 194 patients suspected of active TB. Diagnosis was confirmed by 1) positive M. tuberculosis cultures, or 2) clinical manifestations or laboratory or pathological findings consistent with active TB and response to specific therapy.

RESULTS

Three patients with indeterminate QFT-G results were excluded. Among the remaining 191 patients, 77 had active TB. When the cut-off concentration of IFN-gamma was set at 0.35 IU/ml, as recommended by the manufacturer, the assay was positive in 69 patients and negative in 122. The sensitivity of the assay was 76.6% in all patients, 74.5% in the 47 patients with PTB and 80.0% in the 30 patients with EPTB. The overall specificity of the assay was 91.2%.

CONCLUSION

Although the specificity of the QFT-G to detect active TB was high and its sensitivity low, it was as accurate for the detection of active EPTB as for PTB when the 0.35 IU/ml INF-gamma cut-off concentration was used.

Identifying pathogenic genetic background of simplex or multiplex retinitis pigmentosa patients: a large scale mutation screening study

BACKGROUND AND PURPOSE

More than half of the retinitis pigmentosa (RP) cases are genetically simplex or multiplex. To date, 37 causative genes of RP have been identified; however, the elucidation of gene defects in simplex or multiplex RP patients/families remains problematic. The aim of our study was to identify the genetic causes of RP in patients with unknown or non-Mendelian inheritance.

METHODS AND RESULTS

Since 2003, 52 simplex RP patients, 151 patients from 141 multiplex RP families, and six sporadic patients with retinal degeneration were studied. A total of 108 exons of 30 RP-causing genes that harboured the reported mutations were screened by an efficient denaturing high performance liquid chromatography (dHPLC) based assay. Aberrant fragments were subsequently analysed by automatic sequencing. Twenty-six mutations, including two frameshift mutations, one single amino acid deletion, and 23 missense mutations, were identified in 28 probands (14.07%). Eighteen mutations have not been reported to date. Three pairs of combined mutations in different genes were identified in two sporadic cases and one multiplex family, indicating the possibility of novel digenic patterns. Of the 23 missense mutations, 21 were predicted as deleterious mutations by computational methods using PolyPhen, SIFT, PANTHER, and PMut programs.

CONCLUSION

We elucidated the mutation spectrum in Japanese RP patients and demonstrated the validity of the mutation detection system using dHPLC sequencing for genetic diagnosis in RP patients independent of familial incidence, which may provide a model strategy for identifying genetic causes in other diseases linked to a wide range of genes.

Non-steroidal anti-inflammatory drug-induced small intestinal damage is Toll-like receptor 4 dependent

BACKGROUND

Enterobacteria and cytokines both play roles in the pathophysiology of NSAID-induced enteropathy. Toll-like receptor (TLR) 4 recognises lipopolysaccharide (LPS), resulting in activation of an inflammatory cascade via the accessory protein MyD88.

AIMS

To investigate role of TLR4 in inflammatory responses in indomethacin-induced enteropathy.

METHODS

Indomethacin was administered p.o. to non-fasting rats and mice to induce small intestinal damage. The extent of such damage was evaluated by measuring the injured area stained dark blue with Evans blue. Rats were given antibiotics (ampicillin, aztreonam or vancomycin) p.o., or intraperitoneal LPS (a TLR4 ligand) or neutralising antibodies against neutrophils, tumour necrosis factor (TNF)-alpha, or monocyte chemotactic protein (MCP)-1. Furthermore, the intestinal ulcerogenicity of indomethacin was examined in TLR4-mutant, TLR4(-/-), and MyD88(-/-) mice.

RESULTS

Indomethacin induced small intestinal damage with an increase in expression of TNF-alpha and MCP-1 in both rats and mice. Antibodies against neutrophils, TNF-alpha and MCP-1 inhibited the damage by 83%, 67% and 63%, respectively, in rats. Ampicillin and aztreonam also inhibited this damage, and decreased the number of Gram-negative bacteria in the small intestinal contents of the rat. However, vancomycin, which exhibited no activity against Gram-negative bacteria, had no preventive effect against this damage. Administration of LPS 1 h after indomethacin aggravated the damage, whereas LPS pretreatment inhibited it with reduction of expression of TLR4 and cytokines. In TLR4-mutant mice, the damage and cytokine expression were markedly inhibited. TLR4(-/-) and MyD88(-/-) mice were also resistant to the damage.

CONCLUSIONS

Indomethacin may injure the small intestine through a TLR4/MyD88-dependent pathway.

Interleukin-10 gene transfer to peritoneal mesothelial cells suppresses peritoneal dissemination of gastric cancer cells due to a persistently high concentration in the peritoneal cavity

Interleukin (IL)-10 has potent biological properties including an inhibitory action on the proliferation and metastasis of various cancer cells. However, it is difficult to maintain a high concentration of this cytokine as it has a short half life. In this study, we evaluated whether peritoneal mesothelial cells (PMCs) could be suitable for maintaining a high concentration of IL-10 using adenoviral gene transfer. We also evaluated the therapeutic effects of an intraperitoneal injection with adenoviral vector containing mouse IL-10 gene (Ad-mIL-10) using a mouse peritoneal dissemination model of MKN45 gastric cancer cells. We demonstrated that in vitro transfection efficiency of a recombinant adenovirus containing the bacterial beta-galactosidase gene (Ad-LacZ) was approximately 10-fold higher for primarily isolated PMCs than MKN45. The entire peritoneum was transfected until 3 weeks after an intraperitoneal Ad-LacZ injection. Ad-mIL-10 treatment increased intraperitoneal IL-10 levels until 3 weeks after treatment, and then significantly inhibited peritoneal cancer growth by inhibiting angiogenesis. This treatment also improved cachexia and prolonged mice survival. We thus concluded that IL-10 gene transfer in PMCs could be a new strategy for the prevention of peritoneal dissemination of gastric cancer due to the resulting persistently high IL-10 concentration in the peritoneal cavity.

Simultaneous equations for calculating the pair density

We propose a practical scheme for calculating the pair density (PD) on the basis of the density functional theory. In order to avoid the N-representability problem of the PD, we implement the variational principle within the set of PDs that are constructed from the single Slater determinants (SSDs). For the kinetic energy functional, we utilize the approximate form that is developed by means of the electron-coordinate scaling laws. The variational principle results in the simultaneous equations for constituent orbitals of the SSD. It yields the best one within the SSD-representable PDs.

Comparison between the vorticity expansion approximation and the local density approximation of the current-density functional theory from the viewpoint of sum rules

We compare the vorticity expansion approximation (VEA) with the local density approximation (LDA) of the current-density functional theory from the viewpoint of sum rules. The VEA formulae satisfy all sum rules which are derived from uniform and nonuniform coordinate scaling properties, while the LDA formulae do not satisfy at least about a third of the sum rules. The validity of the VEA formula is thus confirmed successfully.

Waning of the specific interferon-gamma response after years of tuberculosis infection

HYPOTHESIS

Memory T-cell responses to specific antigens wane over time in subjects with tuberculosis (TB) infection.

SETTING

Accumulated evidence indicates that QuantiFERON-TB Gold (QFT-G), a specific whole-blood interferon-gamma (IFN-gamma) based assay, can detect recent TB infections with superior sensitivity and specificity.

OBJECTIVE

We applied this technique to the adult population of a Japanese community to determine its epidemiological usefulness.

METHOD

A total of 1559 subjects attending periodic health screening volunteered to participate in the study.

RESULTS

The QFT-G positive rates were 3.1% for those aged 40-49 years, 5.9% for those aged 50-59 and 9.8% for those aged 60-69. The expected infection prevalence estimated by the authors from a series of studies was 11.1%, 29.6% and 53.1% for those aged 40-49, 50-59 and 60-69 years, respectively. This wide gap between the expected and observed positivity suggests that the IFN-gamma response waned substantially with time after infection. Those with X-rays suggestive of old TB lesions exhibited positivity rates well below 100%.

CONCLUSION

The specific IFN-gamma response may wane considerably with time after infection. Longitudinal studies are required to investigate long-term dynamics of cell-mediated immunity in infected donors.

Comparison of gastrointestinal symptoms and psychological factors of functional dyspepsia to peptic ulcer or panic disorder patients

Symptoms of functional dyspepsia (FD) may look like those of peptic ulcers or panic disorders. But, there is no comparative data between the symptoms of peptic ulcers or panic disorders.

METHODS

To evaluate general symptoms, we used the previously validated questionnaires: 1. the Gastrointestinal Symptom Rating Scale (GSRS), 2. the Self-Rating Depression Scale (SDS), 3. the State-Trait Anxiety Inventory (STAI), and 4. the Coping Inventory for Stressful Situations (CISS). Ninety-six patients with FD (ulcer-like, dysmotility-like, and nonspecific: 28.1 %, 41.7 %, and 30.2 %) diagnosed according to the Rome II criteria, 24 peptic ulcer patients, 21 panic disorders, and 50 healthy controls were enrolled in this study.

RESULTS

Total GSRS score of FD was higher than controls (12.8 +/- 1.2 vs. 5.9 +/- 0.7), and similar to peptic ulcers. Ratio over than a cut-off SDS score of FD was higher than controls (28 % vs. 11 %), although it was lower than panic disorders (65 %). Ratios over than cut-off scores of state- and trait-anxiety of FD were higher than controls (74 % and 62 % vs. 50 % and 36 %) and tended to be higher than peptic ulcers. Positive ratio of state-anxiety scores of FD was similar to panic disorders. As these scores increased, morbidity rate of FD (FD/FD+control) increased (P for trend <0.01). Among CISS scores, task-oriented coping scores of FD tended to be low compared to controls, but emotion-oriented coping scores of FD and controls were significantly lower than panic disorders.

CONCLUSION

Severity of gastrointestinal symptoms but not anxiety of FD was similar to peptic ulcers. Psychological scales of FD were also similar to panic disorders except for the emotion-oriented coping. These findings suggested that the complicated pathogenesis of FD was similar to but not completely consistent with peptic ulcers or panic disorders.

Successful treatment of S-1 + CDDP followed by salvage EMR for a case with metastatic Barrett's esophageal cancer

A 62-year-old woman with Barrett's esophageal cancer was hospitalized. Abdominal CT confirmed metastases to the liver and lymph nodes, for which surgical excision and radiotherapy were not indicated. We started chemotherapy with a course of daily oral S-1 at a dose of 80 mg/m(2) for 21 days, with a 2-hour drip of cisplatin at 60 mg/m(2) on day 8. Breaks of 14 drug-free days were given between courses. After two courses, a repeat CT confirmed that the liver and lymph node metastases had disappeared; after three courses, another CT confirmed that the metastatic foci were still absent, so we judged the disease to be in complete remission. Endoscopy and upper GI series confirmed that the primary tumor was reduced, and endoscopic mucosal resection performed using the strip biopsy method. The excision specimen was well differentiated adenocarcinoma, and mucosal invasion, and the excision stump was negative. After two more courses of S-1 + cisplatin, chemotherapy has been suspended with the patient's consent, and in the 21 months after endoscopic mucosal resection, no recurrence has been observed. This is a rare case of metastatic Barrett's esophageal cancer in which the metastases were eradicated by S-1 + cisplatin, and the primary tumor successfully excised by endoscopic mucosal resection after downstaging.

A diagnosis support system for capsule endoscopy

The diagnostic time required for a full, 8-hour video capsule endoscopy is usually between 45 and 120 min. The aim of this work is to evaluate the diagnostic time required when applying a method that adaptively controlls the image display rate. The advantage of the method is that the sequence can be played at high speed in stable smooth sequences to save time and then decreased at sequences where there are sudden rough changes, in order to assess suspicious findings detail. In this paper, this method is examined under real conditions: 10 sequences were independently evaluated by 4 medical doctors. The methods of evaluation include: 1) the time required for reading a sequence, 2) the percentage of abnormal regions accurately found, and 3) the manipulations of the evaluating physicians. The results indicate that the proposed method reduces diagnostic time to around 10 +/- 1.5% length of the sequence and is of valuable assistance to medical doctors.