[A case of pancreatic carcinoma presenting as pancreaticopleural fistula with pancreatic pleural effusion]

A 63-year-old man was admitted with left pleural effusion, and an amylase level of 30994IU/l. A diagnosis of pancreaticopleural fistula was made, based on the findings of magnetic resonance cholangiopancreatography and endoscopic retrograde pancreatography (ERP). After the placement of an endoscopic naso-pancreatic drainage tube, the pleural effusion markedly reduced. When ERP was performed for internal drainage, the main pancreatic duct and stricture were biopsied and showed pancreatic ductal adenocarcinoma histologically. CT revealed a mass in the head of the pancreas. He underwent pylorus-preserving pancreaticoduodenectomy. To the best of our knowledge this is the first case of pancreatic carcinoma presenting as pancreaticopleural fistula with pancreatic pleural effusion. Clinicians should pay attention to the possible presence of cancer and pancreaticopleural fistula in patients with pancreatic pleural effusion.

Expression of a Rho guanine nucleotide exchange factor, Ect2, in the developing mouse pituitary

The pituitary gland is a highly mitotically active tissue after birth. Various cell types are known to undergo proliferation in the anterior pituitary. However, little is known about the mechanisms regulating mitotic activity in this tissue. When searching for genes specifically expressed in the pituitary gland among those that we previously screened in Drosophila, we found epithelial cell-transforming gene 2 (Ect2). Ect2 is a guanine nucleotide exchange factor for Rho GTPases, which is known to play an essential role in cytokinesis. Although there have been many cellular studies regarding the function of Ect2, the temporal and spatial expression patterns of Ect2 in vivo have not been determined. In the present study, we examined the postnatal developmental expression of Ect2 in the mouse pituitary. Enhanced Ect2 expression was detected in the mouse pituitary gland during the first 3 weeks after birth, which coincided well with the period of rapid pituitary expansion associated with increased growth rate. Immunostaining analysis showed that Ect2-expressing cells were distributed in the anterior and intermediate lobes, but not the posterior lobe, of the pituitary. These Ect2-expressing cells frequently incorporated the thymidine analogue, EdU (5-ethynyl-2'-deoxyuridine), indicating that these cells were mitotically active. Taken together, the results demonstrate the functional role of Ect2 in postnatal proliferating cells in the two lobes of the pituitary, thereby suggesting roles in developmental growth of the mammalian pituitary.

Abstract 3440: Activation of hedgehog pathway in tumor vasculature is a late event of pancreatic tumorigenesis

Bone marrow cells can be activated to function as instigators of tumor growth by systemic tumor-derived signals. We have identified subsets of BM cells that regulate neovascularization in pancreatic ductal adenocarcinoma (PDAC). Notably, blockade of Hedgehog (Hh) signaling markedly destabilized neovessels in PDAC xenografts by attenuating the homing and incorporation of the BM-derived cells into the neovasculature. We found IGF-1 production in the tumor stroma was regulated by the Hh ligand, Shh, and played a key role during this process. In vitro co-culture experiments demonstrated that human PDAC cell lines induced IGF-1 in c-Kit+ BM derived mononuclear cells utilized as pro-angiogenic cells, and that the induction was attenuated either by cyclopamine or expression of shRNA targeting Smo in the mononuclear cells. Shh secreted from PDAC cells induced tube formation by the mouse endothelial line MS-1, suggesting an important role for Shh in migration and capillary formation of the BM-derived pro-angiogenic cells; this induction of capillary morphogenesis was blocked by anti-IGF-1 neutralizing antibody. The “paracrine” effect of Hh seems to be a late event during pancreatic tumorigenesis, as full length Gli2 expression in neovasculatures was detected within PDAC lesions, but not in precursor PanIN lesions using a genetically engineered mouse models. We also observed upregulation of VE-cadherin, Id1, and Ptch1 mRNA in lineage-/c-Kit+ fraction of BM mononuclear cells from PDAC mice as compared to control mice or mice with PanIN, suggesting that pro-angiogenic conditions induced at the level of the BM in cancer-bearing hosts. The primitive progenitors derived from ‘activated BM’ are imported to the tumor microenvironment where they become fully activated. Overall, these studies provide insights into the cellular and molecular mechanisms by which BM-derived cells promote tumor growth and angiogenesis and have implications for the design of anti-angiogenesis therapies.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 3440.

Hedgehog promotes neovascularization in pancreatic cancers by regulating Ang-1 and IGF-1 expression in bone-marrow derived pro-angiogenic cells

Background

The hedgehog (Hh) pathway has been implicated in the pathogenesis of cancer including pancreatic ductal adenocarcinoma (PDAC). Recent studies have suggested that the oncogenic function of Hh in PDAC involves signaling in the stromal cells rather than cell autonomous effects on the tumor cells. However, the origin and nature of the stromal cell type(s) that are responsive to Hh signaling remained unknown. Since Hh signaling plays a crucial role during embryonic and postnatal vasculogenesis, we speculated that Hh ligand may act on tumor vasculature specifically focusing on bone marrow (BM)-derived cells.

Methodology/Principal Findings

Cyclopamine was utilized to inhibit the Hh pathway in human PDAC cell lines and their xenografts. BM transplants, co-culture systems of tumor cells and BM-derived pro-angiogenic cells (BMPCs) were employed to assess the role of tumor-derived Hh in regulating the BM compartment and the contribution of BM-derived cells to angiogenesis in PDAC. Cyclopamine administration attenuated Hh signaling in the stroma rather than in the cancer cells as reflected by decreased expression of full length Gli2 protein and Gli1 mRNA specifically in the compartment. Cyclopamine inhibited the growth of PDAC xenografts in association with regression of the tumor vasculature and reduced homing of BM-derived cells to the tumor. Host-derived Ang-1 and IGF-1 mRNA levels were downregulated by cyclopamine in the tumor xenografts. In vitro co-culture and matrigel plug assays demonstrated that PDAC cell-derived Shh induced Ang-1 and IGF-1 production in BMPCs, resulting in their enhanced migration and capillary morphogenesis activity.

Conclusions/Significance

We identified the BMPCs as alternative stromal targets of Hh-ligand in PDAC suggesting that the tumor vasculature is an attractive therapeutic target of Hh blockade. Our data is consistent with the emerging concept that BM-derived cells make important contributions to epithelial tumorigenesis.

[Primary diaphragmatic schwannoma which needed to be distinguished from a liver tumor]

A 55-year-old woman was admitted because of a tumor located in the ventral region of S4 of the liver, just beneath the diaphragm. A CT scan revealed the round tumor to be delineated as a 33 mm in size, with an outer capsule. The tumor was visualized as concentric circles which presented high-, low-, and high- signal patterns on T2-weighted MRI. It also presented a triphasic pattern in which the border and the central part were not contrasted as a low signal pattern, while the middle part was contrasted as a high signal pattern by T1-weighted enhanced imaging with Gd-DTPA. Angiography revealed that the tumor did not originate from the liver but from the diaphragm, so it was surgically resected as a primary diaphragmatic tumor. We report a schwannoma which originated from the diaphragm, that showed characteristic imaging findings and required to be distinguished from a liver tumor.

[Gemcitabine in combination with S-1 or UFT in patients with advanced pancreatic cancer]

The present retrospective study aimed to evaluate the anti-tumor activity and toxicity of combination chemotherapy with gemcitabine (GEM) and oral S-1 or UFT in patients with advanced or metastatic pancreatic cancer. Ninety-four patients received chemotherapy. Among them, sixty-three were treated with GEM alone, twenty-two with UFT and GEM (UFT/GEM), and nine with S-1 and GEM(S-1/GEM). The median survival time was 8.7 months with GEM, 7.3 months with UFT/GEM, and 23.3 months with S-1/GEM. The overall response rate was 11.1%, 10.0%, and 22.2%, respectively. The 1-year survival rate was 29.5%, 36.4%, and 85.7%, respectively. Although the treatment-related adverse effects were not infrequent in patients treated with S-1/GEM, they were moderate in intensity. The combination chemotherapy with S-1/GEM was well tolerated and yielded a high response rate in patients with pancreatic cancer.

Tumor doubling time in two cases of main duct intraductal papillary-mucinous neoplasms of the pancreas

The present study reports the growth rate in two cases of main duct pancreatic intraductal papillary-mucinous neoplasms (MD-IPMNs) demonstrating significant changes over several years' observation. The first patient was a 74-year-old woman with an incidental finding of diffuse dilatation of the main pancreatic duct (MPD). Endoscopic retrograde pancreatography (ERP) identified a 5 mm filling defect. Three years later computed tomography (CT) revealed a 20 mm mass occupying the MPD. The second patient was a 67-year-old woman who presented with back pain. Abdominal CT revealed a 5 mm mass in the dilated MPD. Five years later, CT and ERP showed a 20 mm mass occupying the markedly dilated MPD. Both patients subsequently underwent pancreatectomy. Histologically, the tumors showed an intraductal papillary growth occupying the dilated MPD and comprised of mucin-containing columnar epithelial cells. The tumor volume doubling time of these MD-IPMNs was 141 and 304 days in patient 1 and 2, respectively, with a mean of 222.5 days. The present reports demonstrate the ability of benign MD-IPMNs to grow at a significant rate, supporting the current consensus guidelines that MD-IPMNs require surgical resection.

[Synchronous double invasive ductal carcinomas of the pancreas with multifocal branch duct intraductal papillary mucinous neoplasms of the pancreas]

A 52-year-old man with a history of distal gastrectomy for gastric cancer was admitted to our hospital because of jaundice. CT scan revealed double tumors in the pancreatic head and body concomitant with multicystic lesions of the pancreas. Total pancreatectomy with splenectomy and remnant gastrectomy was performed. Final histological diagnosis was double invasive ductal carcinomas of the pancreas head and tail with multifocal branch duct intraductal papillary mucinous adenomas of the pancreas. The present case suggests that entire pancreas might have malignant potential in patients with intraductal papillary mucinous neoplasms.

[Case with Todani's type Ib congenital cystic dilatation of the common bile duct]

A 56-year-old man, who had epigastralgia and abnormal liver function test, was admitted to our hospital. ERCP showed common bile duct dilation and stones. We therefore performed endoscopic lithotripsy after endoscopic sphincterotomy. Ten months later, MRCP showed recurrent CBD stones. After rehospitalization, resection of the dilated bile duct was carried out. This case was diagnosed Todani's type Ib congenital cystic dilatation of common bile duct. Todani's type Ib is rare type of congenital dilatation of bile duct, and is interesting embryologically.

[Milk-of-calcium in a pseudocyst of the pancreas]

A 59-year-old woman with a history of abdominal injury was admitted to our hospital for abdominal discomfort. CT revealed a cyst showing a fluid-calcium level in the pancreatic body. EUS-FNA was performed to aspirate the fluid in a cyst. Aspirated was milky-white odorless material. Chemical analysis showed high amylase level in the fluid. Spectroscopic analysis revealed that the fluid mainly consists of calcium phosphate. To the best of our knowledge, this is the first case of milk-of-calcium in a pancreatic pseudocyst with an analysis of cystic fluid obtained by EUS-FNA.

Presence of halophilic and alkaliphilic lactic acid bacteria in various cheeses

AIM

We sought to confirm the presence of halophilic and alkaliphilic lactic acid bacteria (HALAB) of marine origin in cheeses and thus contribute to the understanding of the roles of LAB flora in cheese ripening.

METHODS AND RESULTS

We used 7% NaCl glucose-yeast extract-peptone-fish extract broth and agar media (pH 9.5) for pour-plating and enrichment culture for 16 cheese samples produced in six European countries. HALAB were present in 9 of the 16 samples at < 20 --> 10(7) CFU g(-1). In three mould-ripened soft cheeses, HALAB counts ranged from 10(6) to 10(7) CFU g(-1) and were one order (two samples) and six orders (one sample) of magnitude greater than that of nonhaloalkaliphilic, common LAB, as enumerated on lactobacilli MRS agar. The 16S rRNA gene sequences (500 bp) of 51 of the 55 isolates examined were identical or similar to that of Marinilactibacillus psychrotolerans or Alkalibacterium olivapovliticus and related species, all of which are HALAB.

CONCLUSIONS

HALAB of possible marine origin were present in various soft, semi-hard and semi-soft cheeses and were highly predominant in some mould-ripened cheeses.

SIGNIFICANCE AND IMPACT OF THE STUDY

HALAB of possible marine origin are members of the microflora of various cheeses and, when dominant, may play a role in the ripening of cheeses. Microbial analysis of LAB flora in cheeses should take into consideration the presence of HALAB.

Gemcitabine chemoresistance and molecular markers associated with gemcitabine transport and metabolism in human pancreatic cancer cells

To identify predictive molecular markers for gemcitabine resistance, we investigated changes in the expression of four genes associated with gemcitabine transport and metabolism during the development of acquired gemcitabine resistance of pancreatic cancer cell lines. The expression levels of human equilibrative nucleoside transporter-1 (hENT1), deoxycytidine kinase (dCK), RRM1, and RRM2 mRNA were analysed by real-time light cycler-PCR in various subclones during the development of acquired resistance to gemcitabine. Real-time light cycler-PCR demonstrated that the expression levels of either RRM1 or RRM2 progressively increased during the development of gemcitabine resistance. Expression of dCK was slightly increased in cells resistant to lower concentrations of gemcitabine, but was decreased below the undetectable level in higher concentration-resistant subclones. Expression of hENT1 was increased in the development of gemcitabine resistance. As acquired resistance to gemcitabine seems to correlate with the balance of these four factors, we calculated the ratio of hENT1 × dCK/RRM1 × RRM2 gene expression in gemcitabine-resistant subclones. The ratio of gene expression decreased progressively with development of acquired resistance in gemcitabine-resistant subclones. Furthermore, the expression ratio significantly correlated with gemcitabine sensitivity in eight pancreatic cancer cell lines, whereas no single gene expression level correlated with the sensitivity. These results suggest that the sensitivity of pancreatic cancer cells to gemcitabine is determined by the ratio of four factors involved in gemcitabine transport and metabolism. The ratio of the four gene expression levels correlates with acquired gemcitabine-resistance in pancreatic cancer cells, and may be useful as a predictive marker for the efficacy of gemcitabine therapy in pancreatic cancer patients.

Effects of amino acid on morphological development and nucleus formation of arachidonic acid-producing filamentous micro-organism, Mortierella alpina

AIMS

Effects of amino acid on morphological development and nucleus formation of arachidonic acid-producing filamentous micro-organism, Mortierella alpina were investigated using flow-through chamber.

METHODS AND RESULTS

Mortierella alpina CBS 754.68 was cultivated in flow through chamber using nutrient-rich, minimal and specific amino acid-containing minimal media. To investigate the effect of amino acid on morphological parameters either 0.28 g l(-1) alanine, 0.53 g l(-1) sodium glutamate one hydrate or 0.42 g l(-1) valine was added to the minimal medium. In a flow-through chamber, the growth of hyphal elements and nucleus formation of arachidonic acid-producing fungus M. alpina were studied on-line, using image analysis techniques. When the Ala- and Val-containing media were used, the hyphal growth units (HGUs) were 90.2 and 86.7 microm per tip, respectively, which were 2.4-fold higher than that in the nutrient-rich medium, indicating that Ala and Val stimulate the elongation of hyphae. The specific nucleus formation rates were Glu->Val-containing media>minimal and nutrient-rich media>Ala-containing medium. The nucleus doubling times in Glu- and Val-containing media were 1.9 and 2 h, respectively, which were not significant different.

CONCLUSIONS

Ala and Val stimulate the elongation of M. alpina hyphae, and nucleus formation rates were Glu->Val->Ala-containing media.

SIGNIFICANCE AND IMPACT OF THE STUDY

Formation of fungal morphology and nucleus were shown using the flow-through chamber coupled with image analysis, which making possible to discuss the relationship between mycelial morphology and nucleus formation of M. alpina.

A Phase I Study of Oral Uracil-Tegafur Prior to Weekly Intravenous Gemcitabine in Patients with Advanced Pancreatic Cancer

<i>Background:</i> Gemcitabine is widely accepted as the first-line agent for advanced pancreatic cancer. The antitumor cell activity of gemcitabine is higher when administered after 5-fluorouracil (5-FU) rather than before 5-FU in an in vitro study. The present study was conducted to define the maximum tolerated dose and dose-limiting toxicity associated with an oral fluoropyrimidine prodrug that combines uracil and tegafur (UFT), given prior to weekly intravenous gemcitabine in patients with advanced pancreatic cancer. <i>Methods:</i> Over a 21-day cycle, gemcitabine was given intravenously over 30 min on days 8 and 15, while UFT was given orally from days 1 to 14. The dose of UFT used was 400 mg per day, given as two doses. The dose of gemcitabine was escalated in a stepwise fashion from 800 (level 1, n = 3) to 900 mg/m² (level 2, n = 6) and then to 1,000 mg/m² (level 3, n = 3), such that totally 12 patients received the combination chemotherapy. <i>Results:</i> During the first cycle, grade 3 leukopenia was observed in 2 patients at dose level 1. Only 1 patient treated at dose level 2 experienced dose-limiting toxicity (grade 3 elevated transaminase), including additional patients treated at this dose level. No grade 3/4 toxicities occurred in patients treated at dose level 3. A significant response was observed in 1 out of 12 patients (8.3%). Seven patients (58.3%) had stable disease, while 4 patients (33.3%) showed disease progression. <i>Conclusions:</i> The combination chemotherapy of oral UFT and gemcitabine was convenient, well tolerated and may benefit patients with advanced pancreatic cancer. Doses recommended for further study of this schedule are gemcitabine 1,000 mg/m² and UFT 400 mg/day.

[Concomitant off-pump coronary artery bypass and left lower lobectomy for lung cancer with pneumoconiosis]

Surgical strategy for patients for lung cancer with coronary disease remains controversial. We performed concomitant off-pump coronary artery bypass grafting (off-pump CABG: OPCAB) and left lower lobectomy with ND 2a lymph nodes dissection for lung cancer with pneumoconiosis. After CABG, due to fixed adhesion of peribronchial lymph node, left lower lobectomy was hard to carry out. Postoperative management was done with much difficulty for massive sputum and pneumonia caused by chronic inflammatory lung disease. As a result, postoperative course has been uneventful for 2 years after operation. In the concomitant OPCAB and lung resection with chronic inflammatory lung disease, whether the synchronous or 2 periods operation was appropriate was still unknown. We think that careful pre- and intraoperative assessment for this disease is important.