Neighboring macrophage-induced alteration in the phenotype of colorectal cancer cells in the tumor budding area

BACKGROUND

A higher number of tumor buds in the invasive front of colorectal cancer (CRC) specimens has been shown to contribute to a poor prognosis in CRC patients. Because macrophages (Mφs) have been demonstrated to alter the phenotype of cancer cells, we hypothesized that the phenotype of CRC cells in the tumor budding (TB) area might be changed by the interaction between CRC cells and Mφs.

METHODS

We assessed the expression of topoisomerase 1 in CRC cells to estimate the acquisition of chemoresistance in CRC. To demonstrate the tumor-stromal interaction between CRC cells and Mφs, we assessed two histological findings, the number of Mφs per single CRC cell and the proximity between CRC cells and Mφs by histological spatial analysis using HALO software.

RESULTS

The expression levels of topoisomerase 1 in CRC cells were decreased in deeper areas, especially in the TB area, compared to the surface area. Our histological spatial analysis revealed that 2.6 Mφs located within 60 μm of a single CRC cell were required to alter the phenotype of the CRC cell. Double-immunofluorescence staining revealed that higher Mφs were positive for interleukin-6 (IL-6) in the TB area and that AE1/AE3-positive CRC cells were also positive for phospho-STAT3 (pSTAT3) in the TB area; thus, the IL-6 receptor (IL-6R)/STAT3 signaling pathway in CRC cells was upregulated by IL-6 derived from neighboring Mφs.

CONCLUSION

IL-6 secreted from the neighboring Mφs would alter the phenotype of CRC cells via IL-6R/STAT3 signaling pathway.

Infliximab Inhibits Colitis Associated Cancer in Model Mice by Downregulating Genes Associated with Mast Cells and Decreasing Their Accumulation

Inflammatory bowel diseases (IBDs), such as Crohn’s disease or ulcerative colitis, can be treated with anti TNF-alpha (TNF-α) antibodies (Abs), but they also put patients with IBDs at risk of cancer. We aimed to determine whether the anti TNF-α Ab induces colon cancer development in vitro and in vivo, and to identify the genes involved in colitis-associated cancer. We found that TNF-α (50 ng/mL) inhibited the proliferation, migration, and invasion of HCT8 and COLO205 colon cancer cell lines and that anti TNF-α Ab neutralized TNF-α inhibition in vitro. The effects of anti TNF-α Ab, infliximab (10 mg/kg) were investigated in mouse models of colitis-associated cancer induced by intraperitoneally injected azoxymethane (AOM: 10 mg/kg)/orally administered dextran sodium sulfate (DSS: 2.5%) (AOM/DSS) in vivo. Infliximab significantly attenuated the development of colon cancer in these mice. Microarray analyses and RT-qPCR revealed that mast cell protease 1, mast cell protease 2, and chymase 1 were up-regulated in cancer tissue of AOM/DSS mice; however, those mast cell related genes were downregulated in cancer tissue of AOM/DSS mice with infliximab. These results suggested that mast cells play a pivotal role in the development of cancer associated with colitis in AOM/DSS mice.

Learning curve of robotic rectal surgery using risk-adjusted cumulative summation: a 5-year institutional experience

PURPOSE

Outline learning phases of robot-assisted laparoscopic surgery for rectal cancer and compare surgical and clinical outcomes between each phase of robot-assisted laparoscopic surgery and the mastery phase of conventional laparoscopic surgery.

METHODS

From 2015 to 2020, 210 patients underwent rectal cancer surgery at Sendai Medical Center. We performed conventional laparoscopic surgery in 110 patients and, laparoscopic surgery in 100 patients. The learning curve was evaluated using the cumulative summation method, risk-adjusted cumulative summation method, and logistic regression analysis.

RESULTS

The risk-adjusted cumulative summation learning curve was divided into three phases: phase 1 (cases 1-48), phase 2 (cases 49-80), and phase 3 (cases 81-100). Duration of hospital stay (13.1 days vs. 18.0 days, respectively; p = 0.016) and surgery (209.1 min vs. 249.5 min, respectively; p = 0.045) were significantly shorter in phase 3 of the robot-assisted laparoscopic surgery group than in the conventional laparoscopic surgery group. Blood loss volume was significantly lower in phase 1 of the robot-assisted laparoscopic surgery group than in the conventional laparoscopic surgery group (17.7 ml vs. 79.7 ml, respectively; p = 0.036). The International Prostate Symptom Score was significantly lower in the robot-assisted laparoscopic surgery group (p = 0.0131).

CONCLUSIONS

Robot-assisted laparoscopic surgery for rectal cancer was safe and demonstrated better surgical and clinical outcomes, including a shorter hospital stay, less blood loss, and a shorter surgical duration, than conventional laparoscopic surgery. After experience with at least 80 cases, tactile familiarity can be acquired from visual information only (visual haptic feedback).

CLINICAL TRIAL REGISTRATION

UMIN reference no. UMIN000019857.

[Pathological Complete Response and Long-Term Survival of a Gastric Neuroendocrine Carcinoma Patient Treated by Neoadjuvant Chemotherapy]

A 64-year-old man with gastric tumor in the antrum had been diagnosed with gastric neuroendocrine carcinoma(NEC) by biopsy and multiple lymph node metastases(#3 and #6)by abdominal computed tomography. After staging laparoscopy showed that there were no non-curative factors, neoadjuvant chemotherapy(S-1/cisplatin[CDDP]: 2 courses)and distal gastrectomy and D2 lymph node dissection were performed. The pathological diagnosis was shown as pathological complete response(pCR). After adjuvant chemotherapy(S-1/CDDP: 2 courses, S-1: 6 courses)was administered, the patient is alive at 8 years without recurrence.

[A Case of Long-Term Survival Achieved after Nivolumab Treatment for Recurrence of Postoperative Advanced Gastric Cancer]

A 75-year-old man with a Type 3 advanced gastric cancer in the middle gastric body and paraaortic lymph node swelling was treated chemotherapy. After treatment, we performed an exploratory laparotomy and curative total gastrectomy. As adjuvant chemotherapy, S-1 treatment was administrated for 4 courses but multiple metastases from left supraclavicular to paraaortic lymph nodes. First, Cape plus CDDP plus T-mab therapy treated. Because of acute renal failure, Cape plus L-OHP plus T-mab was administrated but response evaluation was PD. In the second-line therapy, Ramucirumab plus paclitaxel was performed 4 courses. Third, we administrated Nivolumab. After 6 courses, response evaluation was PR and we continued 24 courses. At the same time, there was acute-onset Nivolumab-induced organizing pneumonia and we treated steroid pulse, azithromycin and introduced home oxygen therapy. At the present, 47 months long-term survival achieved after Nivolumab treatment.

Transanal total mesorectal excision and transabdominal robotic surgery for rectal cancer: A retrospective study

Background

Transabdominal robotic surgery and transanal total mesorectal excision (TaTME) are newly introduced strategies for rectal cancer. These procedures might have many advantages in rectal cancer treatment in terms of improving oncological and functional outcomes, especially in cases involving advanced cancer or technical difficulty. In the present study, we aimed to clarify the advantages and disadvantages of transabdominal robotic surgery and laparoscopic TaTME as a hybrid surgery for rectal cancer.

Materials and methods

We retrospectively evaluated six patients who underwent hybrid surgery for rectal cancer from August 2018 to April 2020. Both clinical and pathological outcomes were assessed.

Results

Two patients showed circumferential margin involvement both before and after neoadjuvant therapy. Three patients were planned to undergo hybrid surgery with intersphincteric resection because of a narrow pelvis. One patient was planned to undergo hybrid surgery for a giant tumor of >10 cm. The median length of hospitalization was 17 days. No patients required conversion to an open procedure. All patients underwent formation of defunctioning ileostomies. Two patients had a stapled anastomosis and four had a hand-sewn coloanal anastomosis. Complications included one case of anastomotic leakage, which was managed conservatively with ultrasound- and computed tomography-guided drainage and antibiotics. Histological analysis revealed that all specimens had a negative radial margin and distal margin. The median number of lymph nodes harvested was 17.5. Two patients showed extensive lymph node metastases, including lateral node metastasis.

Conclusion

Hybrid surgery was performed safely and may improve oncological outcomes for rectal cancer. This technique has many potential benefits and would be alternative option in multimodal strategies for rectal cancer.

•

No studies to date have focused on treatment of locally advanced rectal cancer in men using intersphincteric resection hybrid technology involving transabdominal robotic surgery with conventional transanal total mesorectal excision.

•

We found that hybrid surgery is feasible and may improve the quality of total mesorectal excision and the rate of radical resection for advanced rectal cancer.

•

Hybrid surgery may improve urinary and sexual function.

•

This technique has many potential benefits and would be an alternative approach for rectal cancer.

Wnt5a in cancer-associated fibroblasts promotes colorectal cancer progression

Cancer-associated fibroblasts (CAFs) are a major component of the tumor microenvironment and have been shown to promote cancer aggressiveness. In our previous study, analysis of expression profiles obtained from paired CAFs and normal fibroblasts from colorectal cancer (CRC) tissue revealed that gene sets related to the Wnt signaling pathway were highly enriched in colorectal CAFs. Furthermore, among the components of the β-catenin-independent Wnt pathway, Wnt5a was highly expressed in CAFs. Since Wnt5a is considered to be a regulator of CRC progression in CAFs, we performed immunohistochemical analysis on Wnt5a in 171 patients who underwent surgery for CRC. Positive staining for Wnt5a was often found in cancer stroma, particularly in fibromatous areas, although the immunoreactivity for Wnt5a was weak in cancer cells. Wnt5a status in CAFs was significantly associated with tumor size, depth of invasion, lymphatic and vascular invasion, lymph node metastasis, TNM stage, and recurrence. Subsequent in vitro analyses using human recombinant Wnt5a protein revealed that cancer cell proliferation and migration were significantly increased by stimulation with Wnt5a. Our findings suggest that Wnt5a-derived CAFs play a crucial role in CRC progression and have potential as a target of anti-cancer therapies.

Potential urinary function benefits of initial robotic surgery for rectal cancer in the introductory phase

We aimed to evaluate the advantages and disadvantages of initial robotic surgery for rectal cancer in the introduction phase. This study retrospectively evaluated patients who underwent initial robotic surgery (n = 36) vs. patients who underwent conventional laparoscopic surgery (n = 95) for rectal cancer. We compared the clinical and pathological characteristics of patients using a propensity score analysis and clarified short-term outcomes, urinary function, and sexual function at the time of robotic surgery introduction. The mean surgical duration was longer in the robot-assisted laparoscopy group compared with the conventional laparoscopy group (288.4 vs. 245.2 min, respectively; p = 0.051). With lateral pelvic lymph node dissection, no significant difference was observed in surgical duration (508.0 min for robot-assisted laparoscopy vs. 480.4 min for conventional laparoscopy; p = 0.595). The length of postoperative hospital stay was significantly shorter in the robot-assisted laparoscopy group compared with the conventional laparoscopy group (15 days vs. 13.0 days, respectively; p = 0.026). Conversion to open surgery was not necessary in either group. The International Prostate Symptom Score was significantly lower in the robot-assisted laparoscopy group compared with the conventional laparoscopy group. Moderate-to-severe symptoms were more frequently observed in the conventional laparoscopy group compared with the robot-assisted laparoscopy group (p = 0.051). Robotic surgery is safe and could improve functional disorder after rectal cancer surgery in the introduction phase. This may depend on the surgeon’s experience in performing robotic surgery and strictly confined criteria in Japan.

Tips for operation of inguinal hernia after implantation of artificial urinary sphincter following radical prostatectomy: report of two cases

Urinary incontinence is one of the common complications after radical prostatectomy along with inguinal hernia. Artificial urethral sphincter implantation is widely accepted as a treatment option. We report two surgical cases of inguinal hernia after artificial urethral sphincter implantation for urinary incontinence following radical prostatectomy. In Case 1, since the device went through the inguinal canal, adhesion around the pubis was extremely hard. In Case 2, the device was placed on the ventral side of the rectus abdominis muscle, so it was operable almost as normal. In each case, the surgical procedure was considered carefully after confirming the location of the device by preoperative computed tomography and ultrasonography. Hernia repair was successfully performed using the Lichtenstein method. There are few reports regarding surgical repair of inguinal hernia following artificial urinary sphincter implantation. Preoperative image and appropriate choice of approach could facilitate safe and secure surgery.

[A Case of Peritoneal Metastasis Resection from GIST of the Small Intestine with Focal Resistance Against Imatinib Mesylate]

A 69-year-old man was referred to our institute for the surgical resection of focal resistant peritoneal GIST during imatinib administration. He had been diagnosed with GIST of the small intestine with liver and peritoneal metastases, and imatinib treatment was initiated. Shortly after imatinib administration, the primary lesion perforated, and thus, partial resection of the small intestine was performed. Imatinib treatment was resumed after the first surgery, and he achieved partial response. However, computed tomography scans obtained 7 months after the first surgery showed focal progression, a peritoneal metastasis near the right kidney. Under the diagnosis of focally imatinib-resistant GIST, local resection of the metastatic tumor was performed. In this case, an exon 11 mutation of c-kit was noted initially. After the imatinib treatment, an additional point mutation was observed in exon 18 that caused resistance to imatinib. Therefore, imatinib treatment was reinitiated after the second surgery, and other metastases were well controlled. In case of GIST with multiple metastases, appropriate treatment should be selected based on the resistance of each lesion.

A Catastrophic Case of Idiopathic Cholesterol Crystal Embolism with Multiple Lethal Complications: A Labyrinth Underneath the Diagnosis of Skin Ulcers in Chronic Kidney Disease Patients

A 66-year-old man was admitted to our hospital because of multiple refractory skin ulcers. Based on his severe systemic arterial calcification and severe calcium-phosphate imbalance due to severe kidney dysfunction, we initially considered calciphylaxis. However, a skin biopsy provided a diagnosis of cholesterol crystal embolization. Although we initiated hemodialysis, steroid treatment, and low-density lipoprotein-cholesterol apheresis, he died of multiple intestinal perforation. An autopsy showed cholesterol crystals occluding multiple organ arterioles. This case suggests that skin ulcers in patients with chronic kidney disease may be an important diagnostic hallmark and may be associated with several serious diseases.

[A Case of Curatively Resected Rectal Cancer with Preservation of Urinary Function after Chemotherapy]

A55 -year-old man was diagnosed with rectal cancer invading the urinary bladder and swollen para-aortic lymph nodes. Since distant metastasis was indicated and total pelvic exenteration was required, 6 courses of chemotherapy with mFOLFOX6 plus panitumumab were performed. After the chemotherapy, the rectal cancer and para-aortic lymph nodes significantly decreased in size, and novel distant metastasis was not observed in CT scans. Therefore, the tumor was considered resectable, and operation was performed. Intraoperative frozen section analysis showed that the para-aortic lymph nodes and surgical margin of the urinary bladder were negative. Thus, low anterior resection of the rectum and partial resection of the urinary bladder were performed. R0 resection was pathologically achieved, and adjuvant chemotherapy with S-1 was administered for 6 months. The patient is alive without recurrence for 10 months. Upfront chemotherapy can be a strategy for advanced rectal cancer with urinary bladder invasion to avoid total pelvic exenteration.

[A Small Rectal Neuroendocrine Tumor of Less Than 5mm with Lymph Node Metastasis]

According to the treatment guideline for rectal neuroendocrine tumor(NET), tumor with a diameter ofC10mm should be resected endoscopically, while tumor with a diameter of>10mm should be resected surgically with lymph node dissection. We experienced a case of a rectal NET with a diameter of 5mm with lymph node metastasis. A 69-year-old man underwent colonoscopy for positive fecal occult blood test. The colonoscopy revealed a submucosal tumor(SMT)with a diameter of 5 mm in the lower rectum. An endoscopic mucosal resection(EMR)was performed after SMT was diagnosed as NET by biopsy. Histopathological findings were NET-G1, 4.5×2.5 mm, v(+), ly(+). Then, laparoscopically assisted rectal resection with D2 lymph node dissection was performed. In histopathological examination, no tumor residue was observed in the specimu; however, a regional lymph node metastasis was detected. Risk factors of lymph node metastasis with rectal NET are a diameter of>10 mm, recessed or ulcerated surface, and lymphovascular invasion. However, we have to keep in mind that lymph node metastasis may occur even in small rectal NET with a diameter of ≤10mm.

[A Case of Laparoscopically Resected Giant Rectal Cancer Following Neoadjuvant Chemoradiotherapy]

A woman in her 40s who presented to a local hospital with bloody stool was referred to our hospital. Colonoscopy showed a rectal tumor, and histological examination showed moderately differentiated adenocarcinoma. CT and MRI revealed that the tumor was 65mm in diameter with no distant metastasis. After the construction of ileostomy, neoadjuvant chemoradiothera- py(NACRT: 45 Gy/25 Fr, S-1 80mg/m2)was performed. The tumor shrank remarkably, and then we performed laparoscopy- assisted low anterior resection. Pathological examination revealed complete disappearance of the cancer cells in the primary site and no appearance of cancer cells in all dissected lymph nodes. NACRT has been recently reported to provide pathological complete response, and these patients are supposed to have a good prognosis. In our case, NACRT enhanced the performance of laparoscopic curative resection while preserving anal function. NACRT should contribute to the curative resection while preserving anal function in patients with locally advanced rectal cancer.

[Two Cases of Locally Recurrent Rectal Cancer Successfully Treated by Carbon Ion Radiotherapy]

Case 1: A female patient in her 60s underwent laparoscopic intersphincteric resection for rectal cancer. After 42 months, the serum level of carcinoembryonic antigen(CEA)was elevated, and PET-CT showed a locally recurrent rectal cancer that increased FDG-uptake. Carbon ion radiotherapy(CIRT)(73.6 GyE/16 Fr)was performed. Serum CEA level and FDG-uptake were normalized. No regrowth of tumor has been found for 12 months. Case 2: A female patient in her 60s underwent abdominoperineal resection for rectal cancer. After 42 months, the serum level of CEA was elevated, and CT revealed a local recurrence of rectal cancer. Subsequently, the tumor was resected; however, resection margin was microscopically positive. Therefore, chemoradiotherapy(S-1, 60 Gy)was performed. At 31 months after local resection, a re-recurrent tumor was noted in her left ischium. Therefore, CIRT(70.4 GyE/16 Fr)was performed. Serum CEA level and FDG-uptake were normalized. No regrowth of tumor has been found for 24 months. CIRT is an effective therapy for locally recurrent rectal cancer.

[Endoscopy-Assisted Partial Duodenal Resection for Duodenal Adenoma in a Patient with Familial Adenomatous Polyposis]

We here report a case of endoscopy-assisted partial duodenal resection for duodenal adenoma in a patient with familial adenomatous polyposis(FAP). A male underwent total proctocolectomy with ileal pouch anal anastomosis in 1997. Since 2004, duodenal adenomas occurred and the atypical grade of adenoma was gradually aggravated. Therefore, he underwent endoscopy-assisted partial duodenal resection in 2013. The pathological finding of the specimen showed well-differentiated tubular adenocarcinoma(pM, ly0, v0). No recurrence has been observed at 4 years after the operation. Endoscopy-assisted partial duodenal resection was minimum invasive surgery and considered to be useful for the patients with duodenal adenoma.

The Risk Factors for Metastasis in Non-Ampullary Duodenal Neuroendocrine Tumors Measuring 20 mm or Less in Diameter

BACKGROUND/AIMS

The treatment strategy for non-ampullary duodenal neuroendocrine tumors (NAD-NETs) ≤20 mm in diameter has not been established. In this study, we aimed to evaluate the detailed characteristics of NAD-NETs ≤20 mm in diameter to clarify the risk factors of subsequent metastasis.

METHODS

The patients with NAD-NETs ≤20 mm in diameter who had been treated at 12 institutions between 1992 and 2013 were enrolled. Clinical records were retrieved, and histopathological findings of all cases were centrally reviewed by 2 pathologists.

RESULTS

We studied 49 patients with a mean follow-up period of 66.5 months. Thirty-five patients were initially treated with endoscopic resection (ER), and 14 with surgery. A univariate analysis revealed the ORs and 95% CIs of the risk factors for metastasis were lymphovascular invasion (12.5 [2.01-77.9]), multiple tumors (9.75 [1.46-65.4]), a tumor size of 11-20 mm (6.67 [1.21-36.6]), and World Health Organization grade G2 (7.13 [1.16-43.9]). Five-year overall and disease-specific survival rates were 86.1 and 97.2%, respectively.

CONCLUSION

This is the first study to demonstrate the risk factors of metastasis in NAD-NETs ≤20 mm in diameter. These findings may be helpful for determining the appropriate therapeutic approach and the clinical strategy of treatment following ER.

The functional outcome and factors influencing the quality of life after ileal pouch anal anastomosis in patients with ulcerative colitis

PURPOSE

The aim of this study was to assess the bowel function and quality of life (QOL) in patients with ulcerative colitis (UC) after total proctocolectomy with ileal pouch anal anastomosis (IPAA).

METHODS

Two questionnaires ["Questionnaire sheet on the bowel function" and "Inflammatory bowel disease questionnaire (Japanese IBDQ)"] were sent to 121 patients with UC who underwent IPAA at Tohoku University Hospital. Seventy-nine patients (65%) participated in the study.

RESULTS

The median number of daily bowel movements was 6.5, which significantly decreased with postoperative time (≤ 1, 1-5, 5-15 years) and increased with age (< 45, ≥ 45 years at colectomy). The ratio of patients who usually had bowel movements at night also significantly decreased with postoperative time and increased with age. The median total IBDQ score was 180. A multivariate analysis showed that "trip activity", "care about where the restroom is", and "bowel movements in the day" were significant independent risk factors for the daily life satisfaction score.

CONCLUSIONS

The bowel function and QOL were acceptable in patients with UC after IPAA; however, patients with a short postoperative time or older age had a lower functional outcome than others.

[A Case of Leiomyosarcoma of the Small Intestine with Intestinal Hemorrhage Due to Intraluminal Penetration]

A 40-year-old man was referred to our hospital because of severe anemia and small intestinal tumor revealed by computed tomography. The enteroscopy exam showed the intraluminal penetration of the tumor, which was considered as a cause of anemia. Although emergency operation was performed laparoscopically, intraoperative findings indicated tumor invasion into peritoneum, and we converted from laparoscopic surgery to open surgery that included concomitant peritoneum resection. Histopathological findings showed spindle-shaped tumor cells with severe atypia. Immunohistochemical study showed tumor cells to be positive for aSMA, but negative for c-kit and CD34, then we diagnosed the tumor as leiomyosarcoma of the ileum. Since leiomyosarcoma of the small intestine is a rare entity, we have reported with literature consideration.

[Multidisciplinary Treatment for Squamous Cell Carcinoma of the Anal Canal]

Chemoradiotherapy(CRT)has been recognized as a standard treatment for locoregional squamous cell carcinoma of the anal canal in Western countries. However, surgery had historically been considered as a standard treatment and there are only a few reports on CRT for anal canal cancer in Japan. In this study, we analyzed medical records of 5 anal canal cancer patients treated with CRT in our hospital between 2005 and 2015. Patients' characteristics were as follows: median age, 70 years (range 42-80 years); male/female, 1/4; and clinical Stage I / III a/ III b, 3/1/1. The regimens of chemotherapy were MMC plus 5-FU in 4 patients and CDDP in 1 patient. The median follow-up period was 30 months(range, 6 to 100 months). After CRT, 4 patients achieved complete response. The other patient with partial response underwent salvage surgery. All patients were alive without recurrence. In conclusion, our retrospective study showed that CRT is considered to be a standard treat- ment for anal canal cancer.

[A Case of Curatively Resected Ascending Colon Cancer with Ovarian Metastasis and Peritoneal Dissemination after Chemotherapy]

A52 -year-old woman was diagnosed with ascending colon cancer with ovarian metastasis and peritoneal dissemination. Since the patient did not have symptoms with intestinal obstruction, mFOLFOX6 plus bevacizumab(Bmab)was performed for 12 cycles. After chemotherapy, the tumors of ascending colon and ovary were significantly shrunken and novel distant metastasis was not observed by CT scans. Therefore, the tumors were considered to be resectable and curative resection was performed. In the surgical findings, the peritoneal disseminations were localized, and right colectomy, bilateral oophorectomy and extirpation of the peritoneal disseminations were performed. R0 resection was pathologically achieved and adjuvant chemotherapy with UFT/UZEL was administrated for 6 months. The patient is alive without recurrence for 1 year. Since right sided colon cancer is less likely to have obstruction, upfront chemotherapy can be a strategy for locally advanced right sided colon cancer with distant metastasis.

[A Successful Case of Conversion Therapy after Chemotherapy for Advanced Rectal Cancer with Inguinal Lymph Node Metastasis]

A70-year-old man was diagnosed with lower rectal cancer with right inguinal lymph node metastasis. Surgical resection was not suitable for this patient. Chemotherapy(IRIS plus bevacizumab followed by XELOX plus bevacizumab)was administered for 16 months. After the chemotherapy, the rectal tumor and lymph node swelling were significantly reduced and distant metastasis was not observed on CT scans. Therefore, the tumor was considered to be resectable and abdominoperineal resection of the rectum with lymph node dissection was performed. On histopathological examination, cancer cells partially remained in the rectal tumor and lateral lymph nodes, although there were no cancer cells in the inguinal lymph nodes. The patient is alive without recurrence a year later. In cases with a good response to chemotherapy, conversion therapy may become an important therapeutic option.

[A Case of Undifferentiated Carcinoma of the Sigmoid Colon That Responded to Paclitaxel and Carboplatin Chemotherapy]

We report a case of a 72-year-old woman who was initially diagnosed with ovarian cancer with peritoneal carcinomatosis. Systemic chemotherapy consisting of paclitaxel and carboplatin(TC)was administered. Although a partial response(PR)was achieved after the 4 courses of TC, this regimen was discontinued due to severe adverse events. Ten months after discontinuation of TC, because abdominal CT and colonoscopy showed an intra-tumoral abscess caused by invasion of the tumor to the sigmoid colon, abdominal total hysterectomy, bilateral salpingo-oophorectomy, and a Hartmann's operation were performed to control the disease symptoms. Pathological examination revealed that the tumor was an undifferentiated carcinoma of the sigmoid colon. This case report suggests that the TC regimen may be effective for treating undifferentiated carcinoma of the colon.

[Resection of a Huge Gastrointestinal Stromal Tumor of the Stomach Following Neoadjuvant Chemotherapy with Imatinib]

We report a case of a huge gastric gastrointestinal stromal tumor(GIST)that was safely resected followingpreoperative imatinib therapy. A 72-year-old woman was hospitalized with severe abdominal distension. Computed tomography revealed a 27×17 cm tumor in the left upper abdominal cavity. The patient was diagnosed with high risk GIST by EUS-FNA. We initiated preoperative adjuvant chemotherapy with imatinib to achieve a reduction of operative risks and functional preservation. After 6 months of chemotherapy, CT showed a reduction in the tumor size and the patient underwent partial gastrectomy and partial resection of the diaphragm. Histologically, most of the tumor cells were replaced by hyalinized collagen and viable cells were scattered only around the blood vessels. Neoadjuvant chemotherapy with imatinib has the potential to become an important therapeutic option for the treatment of huge GISTs.

Early experience of robotic surgery for type I congenital dilatation of the bile duct

Laparoscopic surgery for this disease is not widely spread due to difficulties in its procedure. We started a laparoscopic procedure for this disease since 2011, and the robotic surgery since 2012. The aim of this study is to assess early results of these procedures. We have operated seven cases from September 2011 through December 2013. First two cases were performed by laparoscopic procedure, and following cases were done by robotically assisted surgery. Of these cases, the perioperative outcome and short-term postoperative morbidity were evaluated. Their average age was 43.6 years old (20-64 years old), and male-female ratio was 2:5. Todani classification was type 1 in all cases. The operation time was 321 min in laparoscopic cases, while 489 min in robotic surgery cases. One case of robotic surgery developed postoperative intestinal obstruction of the biliary limb, requiring laparoscopic adhesiolysis. Pancreatic fistula and anastomotic leakage have not been observed. The robotic surgery for the congenital dilatation of the bile duct is feasible and is a theoretically useful option, especially for hepatico-jejunostomy. On the other hand, the limitation of energy devices, high running cost, and time consumption remain questionable.

[Total Pelvic Exenteration for Local Recurrence of Rectal Cancer Appearing 12 Years after Curative Operation--A Case Report]

A 49-year-old man had undergone Hartmann's operation for rectal cancer in August 2002. The disease stage (TNM 7th) was T3, N1, M0, Stage ⅢB. He was treated with UFT and Krestin for a year as adjuvant chemotherapy. No recurrence had been detected after the surgery. In July 2014, he presented with symptoms of acute renal failure. A CT scan showed bilateral hydronephrosis and a pelvic tumor between the urinary bladder and rectum. The pathological diagnosis based on biopsy specimens was adenocarcinoma. Because immunostaining studies of the tumor biopsy specimen revealed that CK20, CEA, CA19-9, and p53 were positive and CK7 and PSA were negative, this pelvic tumor was diagnosed as a local recurrence of rectal cancer. Total pelvic exenteration and ileal conduit urinary diversion were carried out for the recurrent tumor with curative intent. The reported recurrence rate of Stage Ⅲ colorectal cancer 5 years after the initial curative operation is 0.67%. Local recurrence of rectal cancer 12 years after the initial operation is quite rare. Immunostaining is helpful to discriminate between rectal cancer and a tumor of the urinary organs. It is important to consider that recurrence of rectal cancer might still occur a long time after the initial operation.

Gastrointestinal toxicities of 5-fluorouracil increase the proportion of regulatory T cells in intestinal tract: advantages of alternate-day S-1 administration

BACKGROUND

5-Fluorouracil (5-FU), a core anticancer agent for malignancies, induces gastrointestinal (GI) toxicities. Despite recent advances in tumor immunology, it still remains unknown how GI toxicities affect antitumor immunity. S-1 is a tegafur-based oral 5-FU prodrug which has been widely introduced in Japan and other countries. The alternate-day S-1 administration has been proposed to minimize its GI and other toxicities without reducing its anticancer efficacy.

METHODS

In this study, two S-1 administration regimens were compared in mice to evaluate their impact of GI toxicities on immunity. In the daily group as a standard administration model, S-1 was administered for 14 days on and 14 days off, and in the alternate-day group as a non-GI toxicity model, S-1 was administered every other day for 28 days. As well as physical findings, regulatory T cells, Th1 cells and other cells in murine lymphoid tissues were analyzed with flow cytometry.

RESULTS

Only the daily group exhibited body weight loss and GI toxicities. In the daily group, a proportion of regulatory T cells in the intestinal lymphoid tissue were demonstrated to be six-fold higher than in the control without S-1, and the proportion of Th1 cells showed a decreasing trend. However, the alternate-day group exhibited almost no change in T-cell subsets.

CONCLUSION

GI toxicities of 5-FU may have a negative influence on antitumor immunity due to increased proportions of regulatory T cells and decreased proportions of Th1 cells. The alternate-day S-1 administration may be a useful regimen with its minimal influence on T-cell subsets.

[Two cases of advanced gastric cancer achieved pathological complete response by preoperative chemotherapy with S-1 plus weekly low-dose CDDP]

We report 2 cases of resectable advanced gastric cancer who achieved pathological complete response by preoperative chemotherapy with S-1 plus weekly low-dose cisplatin (CDDP). S-1 (80 mg/m²)was administered consecutively for 21 days followed by 14 days' rest, with CDDP (25mg/m²) injected on days 1, 8, and 21. Case 1: A man in his 70s diagnosed with cStage III gastric cancer with lymph node metastases received 2 courses of preoperative chemotherapy with S-1 plus weekly low-dose CDDP followed by total gastrectomy with D2 lymph node dissection. Case 2: A man in his 60s diagnosed with cStage III gastric cancer with lymph node metastases received 4 courses of preoperative chemotherapy with S-1 plus weekly low-dose CDDP followed by total gastrectomy with D2 lymph-node dissection. In both cases, postoperative pathological examination revealed no cancer cells in the resected stomach and lymph nodes. The therapeutic effect of preoperative chemotherapy was assessed as Grade 3. With this regimen, we accomplished preoperative chemotherapy successfully without inpatient care. This regimen can be a promising option as preoperative chemotherapy for advanced gastric cancer.

[A case of pathological complete response to lt. Lateral lymph node metastasis from lower rectal cancer by S-1 combined neoadjuvant chemoradiotherapy]

A 54-year-old man presented with an enlarged left (lt) lateral lymph node (LLN), which was detected by magnetic resonance imaging (MRI) and positron emission tomography/computed tomography (PET-CT). Endoscopic examination of the colon revealed the presence of a type 1 tumor, 20mm in diameter, in the lower rectum; the tumor was diagnosed as a well-differentiated adenocarcinoma (tub1). The patient received combined neoadjuvant chemoradiotherapy (nCRT)with S- 1 for treatment of the rectal cancer and LLN metastasis (MP, T2N3M0, Stage IIIb). S-1 was administered orally at a dose of 120 mg/day on days 1-14, and 22-35; a total dose of 45 Gy was delivered (1.8 Gy/day, for 25 days). Upon nCRT, there was a remarkable reduction in the tumor size, the primary tumor receded, and the LLN decreased from 16 mm to 8 mm in diameter. The maximum standardized uptake value (SUVmax) also decreased from 3.8 to 1.9 on PET-CT. Six weeks after nCRT, ultralow anterior resection and bilateral lymph node dissections were performed. Histopathological examination showed a partial presence of cancer cells in the scarred primary tumor; however, no viable cancer cells were observed in the lt. LLN.

[A case report of complete pathological response of a locally advanced rectal cancer after long term chemotherapy]

A-39-year-old man presented to a nearby clinic owing to long-term diarrhea and painful defecation. He was diagnosed with a well-differentiated tubular adenocarcinoma of the rectosigmoid and underwent a laparotomy at another hospital. At surgery, the tumor was seen to deeply invade into the urinary bladder with the presence of intra-abdominal abscess. Loop sigmoid colostomy was performed due to possible invasion into the pelvic wall and peritoneal dissemination. The patient was referred to the our hospital for systemic chemotherapy. After 32 courses of FOLFIRI, 10 courses of CapeOX + Bmab, and 34 courses of LV5FU2 + Bmab, radiographic examination revealed complete response (CR) of the rectal tumor, and low anterior resection of the rectum was carried out. Since pathological examination showed no viable cancer cells in any specimen, the patient was considered to have achieved a CR from a pathological standpoint.

Abstract 2832: Single nucleotide polymorphisms of DPYD and MTHFR predict adverse events associated with 5-fluorouracil in patients with gastrointestinal cancer

Purpose

The aim of this study was to investigate the association between 5-fluorouracil (5-FU)-related adverse events (AEs) in Japanese patients with gastrointestinal cancer treated with 5-FU and the patient genotypes DPYD, MTHFR, OPRT, and TYMS.

Methods

Sequence analyses of 33 gene polymorphisms in four genes were performed using genomic DNA extracted from peripheral blood mononuclear cells of 103 patients with gastric (n = 34) or colorectal (n = 69) cancer. The 5-FU-related AEs of 157 regimens in these 103 patients were evaluated based on the medical records of patients in each of three groups: the intravenous administration group (i.v. group, n = 51), oral administration group (p.o. group, n = 106), and all-regimens group (both i.v. and p.o. group, n = 157). The associations between the incidence of AEs and each genotype were statistically analyzed.

Results

Six single-nucleotide polymorphisms (SNPs) were identified (three SNPs in DPYD: c.496A&gt;G, c.1905+1G&gt;A, and c.2303C&gt;A; two SNPs in MTHFR: c.677C&gt;T and c.1298A&gt;C; and one SNP in OPRT: c.638G&gt;C). Among them, the patients in the all-regimens group carrying any one of three DPYD SNPs showed statistically significant associations with the incidence of AEs of any type and fatigue. Furthermore, the MTHFR SNP c.1298A&gt;C was significantly associated with the incidence of neutropenia. A similar trend was observed in the p.o. group, but not in the i.v. group.

Conclusion

These findings suggest that the DPYD SNPs c.496A&gt;G, c.1905+1G&gt;A, and c.2303C&gt;A and the MTHFR SNP c.1298A&gt;C may be predictive factors for the occurrence of severe 5-FU-related AEs.

Citation Format: Masahide Toshima, Shinobu Ohnuma, Michiiro Tanaka, Koh Miura, Wataru Fujibuchi, Taiki Kajiwara, Toshihiro Komura, Hiroaki Musha, Sho Haneda, Katsuyoshi Kudoh, Atsushi Kohyama, Takeshi Naitoh, Michiaki Unno. Single nucleotide polymorphisms of DPYD and MTHFR predict adverse events associated with 5-fluorouracil in patients with gastrointestinal cancer. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 2832. doi:10.1158/1538-7445.AM2014-2832

Abstract 631: Gastrointestinal toxicities of 5-FU increase the proportion of regulatory T cells in murine intestinal tract: Advantages of alternate-day S-1 administration

[Introduction] 5-fluorouracil (5-FU), a core anticancer agent used for various malignancies, induces gastrointestinal (GI) toxicities. The tegafur-based oral 5-FU prodrug S-1 is recognized to be a key drug for GI and other malignancies in Japan and some Asian countries. S-1 was developed to potentiate antitumor activity of 5-FU and to reduce gastrointestinal toxicities. However, S-1 also causes GI toxicities by the standard daily regimen. On the other hand, the alternate-day administration of S-1 has been proposed to minimize toxicities without reducing the anticancer efficacy of 5-FU. Recently, tumor immunology has greatly advanced, and the role of T cells in antitumor immunity has been well investigated. However, it remains unknown how GI toxicities of 5-FU affect T cell subsets related to antitumor immunity.

[Purpose] The purpose of this study is to clarify the influence of 5-FU mediated GI toxicities on T cell subsets related to antitumor immunity.

[Methods] Two regimens of S-1 were compared to evaluate the impact of GI toxicities of 5-FU on T cells using Balb/c mice. The first regimen consisted of the daily administration of S-1 (daily group) as a 5-FU GI toxicity model, and the second regimen consisted of the alternate-day administration of S-1 (alternate-day group) as a 5-FU non-GI toxicity model. S-1 was orally administered at a dose of 12 mg/kg as tegafur. We then investigated the degree of GI toxicities and T cell subsets in intra-abdominal lymphoid tissues (spleen, mesenteric lymph node and gut-associated lymphoid tissue).

[Results] Only the daily group exhibited body weight loss and GI toxicities. Flow cytometric analyses demonstrated that the proportion of regulatory T cells in the intestinal tissue was 6-fold higher in the daily group than that in the control group, and the proportions of Th1 cells in the daily group showed a decreasing trend. However, the alternate-day group exhibited almost no changes in the proportions of T cell subsets.

[Conclusions] GI toxicities of 5-FU increase the proportion of regulatory T cells in intestinal tissue and decrease the proportions of Th1 cells systemically, which suggests that GI toxicities of 5-FU have a negative influence on T cell-dependent antitumor immunity, and the alternate-day administration of S-1 has neither GI toxicities nor the influence on T cell subsets, which suggests that 5-FU regimens without GI toxicities are more useful than those with GI toxicities from the viewpoint of antitumor immunity.

Citation Format: Taiki Kajiwara, Koh Miura, Shinobu Ohnuma, Tetsuhiko Shirasaka, Toshihiro Komura, Masahide Toshima, Atsushi Kohyama, Katsuyoshi Kudoh, Sho Haneda, Hiroaki Musha, Fuyuhiko Motoi, Yu Katayose, Takeshi Naitoh, Michiaki Unno. Gastrointestinal toxicities of 5-FU increase the proportion of regulatory T cells in murine intestinal tract: Advantages of alternate-day S-1 administration. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 631. doi:10.1158/1538-7445.AM2014-631

Abstract 792: Usefulness of alternate-day administration of S-1 and leucovorin in a xenograft mouse model of colorectal cancer: A shorter drug-free interval leads to more efficient antitumor effects

[Background] A clinical trial of S-1 with leucovorin (S-1/LV) in metastatic colorectal cancer (CRC) patients demonstrated promising efficacy; however, the gastrointestinal toxicities were so severe that it has not been applied in the clinical setting. On the other hand, alternate-day administration of S-1 has been proposed to attenuate the adverse events without reducing its anticancer activity. The aim of this study was to confirm the feasibility of alternate-day administration of S-1/LV in in vivo xenograft tumor models.

[Methods] Mice were treated with S-1/LV either in a daily group (two weeks of administration followed by two weeks of withdrawal) or an alternate-day group (administration on alternate days for four weeks), then the mice of both groups were sacrificed and the xenograft tumors were resected. To assess the adverse reactions, the body weight changes, the condition of feces, mucosal injury of small intestine and myelosuppression were compared between both groups. Furthermore, tumor volume, tumor growth inhibition (TGI) and the expression of Ki67, TUNEL, cIAP2 and XIAP were analyzed to evaluate the antitumor activity and tumor apoptosis.

[Results] Severe weight loss, diarrhea, mucosal injury and myelosuppression were observed only in the daily group; however, no adverse reactions were observed in the alternate-day group, except slight myelosuppression. The TGI in the alternate-day group was better than that in the daily group, possibly resulting from apoptosis of tumor cells due to the suppression of cIAP2.

[Conclusion] Our findings suggest that alternate-day administration of S-1/LV for CRC treatment can achieve higher antitumor activity without severe adverse reactions. Therefore, we propose that clinical trials with this regimen should be conducted in CRC patients.

Citation Format: Toshihiro Komura, Shinobu Ohnuma, Koh Miura, Tetsuhiko Shirasaka, Taiki Kajiwara, Katsuyoshi Kudoh, Sho Haneda, Masahide Toshima, Atsushi Kohyama, Hiroaki Musha, Takeshi Naitoh, Yu Katayose, Michiaki Unno. Usefulness of alternate-day administration of S-1 and leucovorin in a xenograft mouse model of colorectal cancer: A shorter drug-free interval leads to more efficient antitumor effects. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 792. doi:10.1158/1538-7445.AM2014-792

The impact of histologic tumor response on survival of patients treated with neoadjuvant mFOLFOX6 plus bevacizumab for the synchronous liver metastases from colorectal cancer

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Background: The synchronous liver metastases (SLM) from colorectal cancer (CRC) have a poor prognosis. Therefore, we conducted a phase II study of neoadjuvant mFOLFOX6 + bevacizumab for SLM to explore the appropriate initial treatment (BeFORE study). Here, assess the impact of histological tumor response (HR) on the relapse-free survival (RFS) and the overall survival (OS). Methods: The main inclusion criteria of BeFORE study were SLM within 10 nodules and with measurable disease. The primary endpoint was the response rate (RR). The secondary endpoints included R0-liver resection rate, HR, RFS and OS. Patients (pts) were enrolled after R0-resection of the primary CRC and received 8 courses of mFOLFOX6 + BV (the first and last courses were mFOLFOX6 alone). After this neoadjuvant chemotherapy, pts underwent resection of liver metastases within 4-8 weeks. HR was re-assessed on the basis of the tumor regression grade (TRG) which evaluates the extent of fibrosis of tumor cells, and the modified TRG which evaluates the extent of fibrosis and therapeutic-associated necrosis, using resected tumor samples. Results: Between June 2008 and November 2010, 47 pts were enrolled and 44 pts were treated per protocol. The median number of metastases was 2 nodules, and the maximum diameter of tumors was 12.9 cm. The overall RR was 72.7%. Forty pts underwent liver resection and 39 pts had the R0-liver resection. Five pts (12.5%) of resected 40 pts achieved TRG 1-2 (major HR), 5 pts (12.5%) had TRG 3 (partial HR) and 30 pts (75.0%) had TRG 4-5 (no HR). 8 pts (20.0%) achieved mTRG 1-2, 8 pts (20.0%) had mTRG 3, and 24 pts (60.0%) had mTRG 4-5. With a median follow-up of 35 months, the 2-year RFS rate was 27.3% (the median RFS was 10.5 months), and the 2-year OS rate was 88.4%. Here, we perform sub-group analyses of RFS and OS by TRG, mTRG, respectively. Conclusions: The impact of HR (TRG, mTRG) on survival could help us with considering about the appropriateness of neo-adjuvant mFOLFOX6 + BV as the initial treatment for SLM. (This trial is on University hospital Medical Information Network-Clinical Trials Registry (UMIN-CTR); UMIN000001568.) Clinical trial information: UMIN000001568.

[Therapeutic strategy for neuroendocrine tumor of the rectum]

The clinicopathological features of neuroendocrine tumor (NET) of the rectum were retrospectively analyzed in 25 patients( 17 men and 8 women; mean age, 57 years[ 30-78 years]) at Tohoku University Hospital from January 1998 to December 2012. The average diameter of 25 tumors was 15 mm (5-70 mm). Local resections and rectal resections with lymph node dissection were performed in 16 and 9 tumors, respectively. Three of the 9 tumors had lymph node metastases (33%), including 2 tumors with a diameter of 10 mm. In a median follow-up of 48 months, tumor recurrence was observed in 3 of 25 patients( 12%); local recurrence was observed in 1 patient; and liver metastasis was observed in 2 patients. Of the 2 patients with liver metastasis, liver metastasis recurred in a patient whose primary tumor, with a diameter of 10 mm, had been locally resected 40 months ago. According to histopathological analysis, 3 primary tumors with local recurrence or liver metastasis were categorized as G2 or G3 according to the World Health Organization (WHO) classification. Tumors with a diameter of ≥10 mm, in principle, may be removed by rectal resection with lymph node dissection. However, histopathological findings such as a proliferation of tumor cells should also be taken into consideration when deciding the treatment strategy for rectal NET.

A phase II multicenter trial of neoadjuvant chemotherapy FOLFOX6 in combination with bevacizumab for patients with resectable synchronous liver metastases after R0-resections of primary colorectal cancers: The interim analysis

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Background: Therapeutic strategies for colorectal cancer (CRC) patients with synchronous liver metastases are still indeterminate; therefore, we conducted a phase II multicenter trial of neoadjuvant chemotherapy mFOLFOX6 combined with bevacizumab for resectable synchronous liver metastases after R0-resections of primary CRCs. This study was started in June 2008. This is the interim report. Purpose: The aim of this interim analysis is to evaluate the response rate (RR) and adverse events (AEs) of the enrolled patients.

Methods: Eligibility criteria included CRC patients with 10 or less synchronous liver metastases that were preoperatively diagnosed as surgically resectable. 20 of the enrolled patients received 8 courses of mFOLFOX6 with bevacizumab, but bevacizumab was omitted at the initial and the final courses, to avoid the AEs at the operations. The primary endpoint was the RR.

Results: Among the 20 patients, one patient was excluded from the study because the assumed metastasis was diagnosed to be hemangioma later with the MRI imaging. RR was analyzed for the 19 patients, and AEs were analyzed for the 20 patients. Complete response and partial response were achieved in 2 (10.5%) and 11 (57.9%), respectively (RR: 68.4%); 4 (21.1%) were stable disease, and 2 (10.5%) were progressive disease. The RR was higher than the prespecified boundary; therefore, this study was scheduled to be continued. AEs were the following: neutropenia, hypertension, anemia, leucopenia, nausea, appetite loss, stomatitis, bleeding and proteinuria. Grade 3 neutropenia occurred in 4 cases (20.0%), and sensory neuropathy, stomatitis, diarrhea, and cerebral infarctions occurred in each one (5.0%) of the patients. There was no AE of grade 4 or 5. Liver resections were performed in 17 cases, and R0-resection was achieved in all of the operable cases (R0 rate was 85%).

Conclusions: Neoadjuvant chemotherapy mFOLFOX6 combined with bevacizumab appears to be effective and well tolerated. The study is continued as scheduled, to further evaluate the benefit of this regimen.

No significant financial relationships to disclose.

[A case of multiple metachronous metastases of colon cancer to the small intestine preoperatively diagnosed by double balloon enteroscopy and radically resected]

The patient was a 75-year-old woman who had undergone resection of a transverse colon cancer two years before. She had anemia and intestinal obstruction, and a diagnosis of multiple metastases to the small intestine was made by double balloon enteroscopy. Eleven metastatic foci were resected by partial resection of the jejunum and ileum. Adjuvant FOLFOX chemotherapy was given, achieving a 26-month disease-free survival. The double balloon enteroscopy was useful in the definitive diagnosis of this case, and aggressive resection with adjuvant chemotherapy contributed to the good outcome.

Effect of angiotensin-converting enzyme gene polymorphism on left ventricular remodeling after anteroseptal infarction

BACKGROUND AND HYPOTHESIS

Genetic influence on cardiac remodeling is uncertain. The purpose of this study is to determine the effects of polymorphism of the angiotensin-converting enzyme (ACE) gene on cardiac remodeling after myocardial infarction.

METHODS

The subjects were 43 patients with old anteroseptal myocardial infarction. Based on the polymorphism of the ACE gene, they were classified into a deletion group of 25 patients (D/D genotype in 4 and D/I genotype in 21) and an insertion group of 18 patients (all I/I genotype). Echocardiograms were used to determine left ventricular end-diastolic and end-systolic diameters, interventricular septal and posterior wall thicknesses, left ventricular mass, left atrial diameter, and left ventricular ejection fraction. Blood concentrations of atrial and brain natriuretic peptide were also measured.

RESULTS

Left ventricular end-systolic and end-diastolic dimensions, left ventricular mass, and levels of both atrial and brain natriuretic peptide were significantly higher in the deletion group. In contrast, septal thickness, posterior wall thickness, and ejection fraction showed no differences between the two groups.

CONCLUSIONS

In patients with old anteroseptal infarction, ACE gene polymorphism of the D/D and D/I genotypes has a stronger influence on left ventricular remodeling than polymorphism of the I/I genotype.

Influence of angiotensin-converting enzyme gene polymorphism on development of athlete's heart

BACKGROUND AND HYPOTHESIS

Genetic influence on development of athlete's heart is uncertain. This study investigated whether angiotensin-converting enzyme (ACE) gene polymorphism influenced development of athlete's heart.

METHODS

Forty-three participants in a 100-km ultramarathon were classified on the basis of ACE gene polymorphism into a deletion group (n = 26) and an insertion group (n = 17). Echocardiograms were recorded to determine left ventricular end-diastolic and end-systolic diameters, interventricular septal thickness, left ventricular posterior wall thickness, left ventricular mass, and ejection fraction.

RESULTS

Left ventricular end-diastolic diameter (65.5 +/- 4.0 mm) and left ventricular mass (369.5 +/- 73.9 g) were significantly larger in the subjects with deletion than in those with insertion (57.4 +/- 4.2 mm, 306.5 +/- 93.7 g). However, no significant differences in the other parameters were noted.

CONCLUSIONS

In long-distance runners, ACE gene polymorphism of the D/D and D/I genotypes has a stronger influence on left ventricular hypertrophy than polymorphism of the I/I genotype.

Left ventricular chamber size predicts the race time of Japanese participants in a 100 km ultramarathon

OBJECTIVE

As a subanalysis of an echocardiographic study performed on 291 Japanese participants in a 100 km ultramarathon, to estimate predictors of race time.

METHODS

A total of 247 male participants in a 100 km ultramarathon (age 20-73 years) were examined by echocardiography. Correlations between age, body surface area, monthly running distance, or echocardiographic variables and the race time were examined.

RESULTS

According to simple regression analysis, age (r = 0.299, p < 0.0001), monthly running distance (r = -0.388, p < 0.0001), left ventricular end diastolic diameter (r = -0.300, p < 0.0001), and left ventricular end systolic diameter (r = -0.325, p < 0.0001) correlated significantly with the race time. When multiple regression analysis was performed, age (f = 2.364), monthly running distance (f = -0.113), and left ventricular end systolic diameter (f = -2.361) remained significant predictors of the race time.

CONCLUSION

Left ventricular diameter predicts the race time for a 100 km ultramarathon, in addition to age and amount of training.

Selective infiltration of CCR5+CXCR3+ T lymphocytes in human colorectal carcinoma

T cell infiltration in colorectal cancer is associated with a favorable prognosis, suggesting an occurrence of a certain degree of anti-tumor immunity. T helper type 1 (Th1) and Th2 cells are now known to selectively express CC-chemokine receptor 5 (CCR5)/CXC-chemokine receptor 3 (CXCR3) and CCR4, respectively. To clarify the mechanism of T cell infiltration, we examined in situ expression of these chemokine receptors and their respective chemokine ligands in 40 cases of human colorectal cancer. Immunohistochemistry showed a predominant accumulation of T cells expressing CCR5 and CXCR3 mainly along the invasive margin, whereas those expressing CCR4 were rare. Flow cytometric analysis showed that more than half of CD8(+) T cells and a fraction of CD4(+) cells isolated from fresh tumor tissues co-expressed CCR5 and CXCR3, and CD8(+) T cells and CD4(+) cells predominantly produced interferon-gamma (IFN-gamma) over interleukin-4 (IL-4) after in vitro stimulation. RANTES/CCL5, a ligand of CCR5, was localized within infiltrating CD8(+) T cells in a granular pattern, whereas IP-10/CXCL10, a ligand of CXCR3, was localized in cancer cells and macrophages along the invasive margin. These data were consistent with an active recruitment of T cells expressing CCR5 or CXCR3 into the invasive margin of colorectal cancer. With the previous clinicopathological studies showing a favorable prognostic impact of T cell infiltration in colorectal cancer, our study supports the occurrence of a certain level of Th1-shifted cellular immune responses in human colorectal cancer.

Plasma brain natriuretic peptide in takotsubo cardiomyopathy

BACKGROUND

Takotsubo cardiomyopathy is a reversible left ventricular dysfunction with symptoms resembling acute myocardial infarction, but without coronary lesions. Patients have wall motion abnormalities (apical akinesis and basal hyperkinesis), and characteristic left ventricular morphology.

AIM

To investigate plasma brain natriuretic peptide (BNP) concentrations in takotsubo cardiomyopathy.

METHODS

Ten consecutive patients with takotsubo cardiomyopathy underwent cardiac catheterization on their first hospital day, and blood was collected to measure BNP. To evaluate acute basal hyperkinesis, the difference in diameter between systole and diastole was measured at 10 mm below the aortic valve (the deltaBase value).

RESULTS

Coronary angiography revealed no significant stenosis in any patient. Initial ejection fraction was 42.2 +/- 7.3%, cardiac index was 1.90 +/- 0.39 l/min/m(2), and plasma BNP was 522.5 +/- 632.9 pg/ml. Ventricular contraction and the ejection fraction were normalized on echocardiography after 17.9 +/- 6.3 days. BNP was significantly correlated with deltaBase, but not with other cardiac parameters.

DISCUSSION

Initial deltaBase value seems to be a good indicator of the severity of basal hyperkinesis in patients with takotsubo cardiomyopathy. In contrast to other diagnoses, a high BNP concentration is not associated with a poor prognosis in this condition.

Evidence for existence of oligoclonal tumor-infiltrating lymphocytes and predominant production of T helper 1/T cytotoxic 1 type cytokines in gastric and colorectal tumors

Tumor-infiltrating lymphocytes (TIL) play a central role in cellular immunity against tumor. We have revealed the characteristics of TILs in terms of T-cell receptor (TCR) repertoire, T-cell clonality, and cytokine production. TCR repertoire analyses and CDR3 size spectratyping were performed using peripheral blood mononuclear cells (PBMCs) and tissue specimens of gastric or colorectal cancers surgically resected from 11 patients. The cytokine expression was measured by real-time quantitative polymerase chain reaction. TCR repertoires were similar among multiple tissue specimens from different sites of the same tumor. Similar peak patterns of CDR3 size spectratyping were observed among these tumor specimens, but not in normal tissues or PBMCs. In addition, identical peaks were detected in multiple specimens of the same tumor. The ratio of the levels of IFN-gamma to that of IL-4 is significantly higher for tumor lesions compared with PBMCs. These results suggested that a limited number of TILs locally expand in response to tumor antigens exiting within gastric or colorectal cancers and local predominant production of the T helper 1/T cytotoxic 1 type cytokine may affect the anti-tumor immune response of TILs.