The Validity of a New Edition of Classification for Ovarian Metastasis from Colorectal Cancer

OBJECTIVES

In the 9th edition of the Japanese Classification of Colorectal, Appendiceal, and Anal Carcinoma (JCCRC), ovarian metastasis is classified as distant metastasis. We assessed the significance of resection of ovarian metastases and the validity of this 9th edition of JCCRC for ovarian metastases from colorectal cancer (CRC).

METHODS

We retrospectively analyzed the clinicopathological factors and overall survival of 17 patients with ovarian metastases from CRC who underwent resection and 110 female CRC patients with Stage IV (M1a) disease.

RESULTS

The patients with only ovarian metastases who underwent resection had a longer median survival time than patients with both ovarian and peritoneal metastases who underwent resection (45.4 months vs. 9.3 months, P = 0.029). The 5-year overall survival of the patients with only ovarian metastases who underwent R0 resection was as long as that of the female Stage IV (M1a) CRC patients after R0 resection (50% vs. 48%, P = 0.334).

CONCLUSIONS

We found that, after resection, patients with only ovarian metastases had significantly better prognoses than patients with ovarian and peritoneal metastases. R0 resection of ovarian metastasis indicated as good prognosis as R0 resection of metastasis to one distant organ without ovaries. So the 9th edition of JCCRC, which classifies ovarian metastasis from CRC as distant metastasis, is appropriate.

Interleukin 13 (IL-13)-regulated expression of the chondroprotective metalloproteinase ADAM15 is reduced in aging cartilage

Objective

The adamalysin metalloproteinase 15 (ADAM15) has been shown to protect against development of osteoarthritis in mice. Here, we have investigated factors that control ADAM15 levels in cartilage.

Design

Secretomes from wild-type and Adam15^−/− chondrocytes were compared by label-free quantitative mass spectrometry. mRNA was isolated from murine knee joints, either with or without surgical induction of osteoarthritis on male C57BL/6 mice, and the expression of Adam15 and other related genes quantified by RT-qPCR. ADAM15 in human normal and osteoarthritic cartilage was investigated similarly and by fluorescent immunohistochemistry. Cultured HTB94 chondrosarcoma cells were treated with various anabolic and catabolic stimuli, and ADAM15 mRNA and protein levels evaluated.

Results

There were no significant differences in the secretomes of chondrocytes from WT and Adam15^−/− cartilage. Expression of ADAM15 was not altered in either human or murine osteoarthritic cartilage relative to disease-free controls. However, expression of ADAM15 was markedly reduced upon aging in both species, to the extent that expression in joints of 18-month-old mice was 45-fold lower than in that 4.5-month-old animals. IL-13 increased expression of ADAM15 in HTB94 ​cells by 2.5-fold, while modulators of senescence and autophagy pathways had no effect. Expression of Il13 in the joint was reduced with aging, suggesting this cytokine may control ADAM15 levels in the joint.

Conclusion

Expression of the chondroprotective metalloproteinase ADAM15 is reduced in aging human and murine joints, possibly due to a concomitant reduction in IL-13 expression. We thus propose IL-13 as a novel factor contributing to increased osteoarthritis risk upon aging.

[Long-Term Survival in a Case of Colon Cancer with Peritoneal Dissemination and Ovarian Metastasis after Multimodality Therapy]

A 70-year-old woman underwent treatment for cecal cancer(pT4bN1M0, Stage Ⅲb)in 2010. Four years and 2 months after the first surgery, she underwent ileum resection for stenosis due to perineal dissemination(P3). Two years after this recurrence, during which time she had completed 26 courses of FOLFIRI plus bevacizumab(Bmab), 9 courses of capecitabine plus oxaliplatin(CapeOX)plus Bmab, and 3 courses of Cape, no peritoneal dissemination was detected by computed tomography( CT). Thereafter, an additional 19 courses of Cape plus Bmab were introduced, but CEA continued to increase. Right ovarian metastasis was suspected based on CT and FDG-PET/CT examination. Four years and 1 month after the initial recurrence of perineal dissemination, the patient underwent bilateral ovarian resection, during which the lack of peritoneal dissemination was confirmed. Pathologically, right ovarian metastasis was diagnosed. The patient is still alive 4 years and 6 months after the first operation.

[A Resected Case of Hemorrhagic Hepatic Cyst Difficult to Differentiate from Mucinous Cystic Neoplasm of the Liver]

CASE

A 77-year-old woman was referred to our hospital for detailed examination of a cystic liver tumor. Contrast-enhanced CT and MRIshowed a cystic liver tumor with an enhanced mural nodule in S6 of the liver. Under a preoperative diagnosis of hemorrhagic hepatic cyst and mucinous cystic neoplasm(MCN)of the liver, extended posterior segmentectomy was performed. Histological examination of the tumor revealed no neoplastic cells, and the tumor was finally diagnosed as a hemorrhagic hepatic cyst of the liver.

CONCLUSION

Similar to previous reports of hemorrhagic hepatic cysts, preoperative differential diagnosis from MCN of the liver was difficult in this case. Hemorrhagic hepatic cysts are rare and are sometimes confused with MCN of the liver, especially when an enhanced mural nodule is found in the cyst. The possibility of hemorrhagic hepatic cysts should be considered during diagnosis of liver cystic tumors.

[A Case of Resection of a Metastatic Tumor Combined with the Spleen, Preserving the Remnant Stomach, for Recurrent Gastric Cancer of the Splenic Hilar Region after Distal Gastrectomy]

We describe a case of residual stomach preserving surgery performed under evaluation of residual gastric blood flow with indocyanine green(ICG)fluorography, for gastric cancer with recurrence of splenic lymph node metastasis after distal gastrectomy( DG)in a 65-year-old man. After 4 courses of S-1 plus CDDP(SP)therapy for advanced gastric cancer with ascites, DG, D2 dissection, and Billroth Ⅰ reconstruction were performed and radical resection was obtained(L, Type 3, pap/tub, ypT3N1H0P0CY0M0, ypStage ⅡB). Three years and 6 months after the surgery, a mass 4 cm in diameter was found in the splenic hilum, and a pancreatosplenial resection was performed to remove the tumor for diagnosis and treatment purposes. We confirmed that there was no problem with blood flow, and we were able to preserve the stomach. Intraoperative ICG fluorescence imaging was considered a promising method for evaluating residual gastric blood flow.

[Gastric Gastrointestinal Stromal Tumor Appearing Nine Years after Resection of a Duodenal Gastrointestinal Stromal Tumor-A Case Report]

Multiple sporadic gastrointestinal stromal tumor(GIST)are rare, except for those restricted to von Recklinghausen disease or hereditary conditions.We reported a case of a gastric GIST resected 9 years after the resection of a duodenal GIST.The patient was a 58-year-old male who had been followed-up with computed tomography scans after pancreatoduodenectomy for a duodenal GIST when he was 49-years-old.The patient was admitted to our hospital for anemia examination.A CT scan detected a tumor in the stomach, with a diameter of over 10 cm, and necrosis.Esophagogastroduodenoscopy revealed the presence of a delle on the gastric SMT.Due to suspected invasion of the spleen and left diaphragm by the tumor, we performed subtotal gastrectomy with splenectomy and left diaphragm segmental resection.In the pathological diagnosis, the tumor was diagnosed as a gastric GIST, because the cell type of the tumor was spindle and tested positive for c-kit.Based on the tumor size and mitotic count, the patient was diagnosed with high-risk GIST by the modified-Fletcher classification, and imatinib 400mg/day was administered.There have been no signs of recurrence for 2 years since the operation.

[Long-Term Survival after Surgical Treatment of Neuroendocrine Carcinoma of the Ampulla of Vater-A Case Report]

A 60s man underwent upper gastrointestinal endoscopy at a regular medical check-up without symptoms, which showed an ulcerative region in the duodenal ampulla, measuring 3 cm in diameter. He was diagnosed with poorly differentiated adenocarcinoma on biopsy and referred to our hospital. Abdominal contrast-enhanced CT scan revealed an enhanced-ulcerative tumor, measuring 3 cm, at the duodenal ampulla. After the preoperative diagnosis of adenocarcinoma of the duodenal ampulla, subtotal stomach-preserving pancreatoduodenectomy with regional lymph node dissection was performed. The final diagnosis was neuroendocrine carcinoma(NEC)of the duodenal ampulla. He has been alive for 9 years with no recurrences. NEC of the duodenal ampulla is rare, and its prognosis is poor. We report a case of long-term survival after resection of NEC of the duodenal ampulla.

[Surgical Outcomes of Laparoscopic Repeat Hepatectomy at Our Institution]

Laparoscopic hepatectomy has gained popularity owing to its merits, such as low invasiveness and reduced bleeding. However, the efficacy of laparoscopic repeat hepatectomy(LRH)has not been confirmed. The aim of this study was to evaluate the feasibility and efficacy of LRH compared to that of open repeat hepatectomy(ORH). We performed 60 repeat hepatectomies from January 2011 to March 2019, of which 19 were LRH(Lap group)and 41 were ORH(Open group). This study retrospectively compared the patient characteristics and short-term outcomes of repeat hepatectomy between the Lap and Open groups. There were no significant differences in patient characteristics, except for the type of approach in the previous hepatectomy(p<0.01). The Lap group had lesser blood loss(median: 150 mL vs 355 mL, p<0.01)and shorter postoperative hospital stays(median: 8 days vs 11 days, p<0.01). There were no differences in operation time or severe postoperative complications. LRH is feasible and useful, providing good short-term outcomes.

[Pulmonary Metastases of Hepatocellular Carcinoma Treated with Repeated Pulmonary Resection-A Case Report]

A 65-year-old man visited our hospital for hepatocellular carcinoma(HCC)and underwent extended posterior sectionectomy. Eight months after the hepatic resection, follow-up computed tomography(CT)revealed a solitary, recurrent tumor in S4 of the liver, and transcatheter arterial chemoembolization and radiofrequency ablation were performed for the intrahepatic recurrence. After 12 postoperative months, follow-up CT demonstrated pulmonary metastases in S5 of the right lung and S10 of the left lung. Since there were no other metastases, the 2 metastatic lesions were resected using video-assisted thoracoscopic surgery(VATS). The resected tumors were histologically diagnosed as pulmonary metastases of HCC. Three years after the pulmonary resection, 3 additional pulmonary metastases were detected on CT in S3 and S10 of the right lung and S4 of the left lung. No other metastases were found. Bilateral VATSmetastasectomy was performed for the metastases. The tumors were diagnosed as pulmonary metastases of HCC on histological examination. One year and 8 months after the surgery, he was alive in a good condition, with no recurrences. The present case suggested that some patients with pulmonary metastasis of HCC can have long-term survival with surgical resection of the metastasis. Therefore, while systemic chemotherapy is generally considered the standard treatment for extrahepatic metastasis of HCC, surgical resection might be an option.

[Intraoperative Assessment of Blood Flow in the Remnant Stomach Using Indocyanine Green and Regional Oxygen Saturation Monitoring at Distal Pancreatectomy Following Gastrectomy]

A92 -year-old man was diagnosed with pancreatic cancer 14 years after undergoing distal gastrectomy for gastric cancer. His remnant stomach was fed by the cardiac branch of the left inferior phrenic artery, short gastric artery, and posterior gastric artery. We planned distal pancreatectomy(DP). Intraoperative indocyanine green(ICG)fluorography showed that the remnant stomach was perfused under the clamp of the splenic artery. We also confirmed that regional oxygen saturation (rSO2)of the remnant stomach was not decreased by the clamp. Based on the findings, we judged that blood flow in the remnant stomach was preserved at the clamp. We then performed DP with preservation of the remnant stomach. Postoperative complications associated with the remnant stomach were not observed. The patient is alive without any postoperative recurrences of pancreatic cancer or trouble associated with the remnant stomach 22 months after the surgery. This case suggested that ICG fluorography and rSO2 monitoring are useful to evaluate blood flow in the remnant stomach.

[A Case of Resected Primary Hepatic Neuroendocrine Tumor]

A 70s man presented with a solitary liver tumor measuring 4.5 cm on CT. On contrast-enhanced CT, the tumor appeared partly well-enhanced in the late phase, and the remaining part was enhanced in the early phase and washed out in the late phase. Contrast-enhanced MRIshowed fused multiple nodules, and the enhancement/washout pattern was clearer than that of the contrast-enhanced CT. The tumor showed a defective image in the hepatobiliary phase and a high signal on diffusionweighted imaging. Then, the tumor was diagnosed as hepatocellular carcinoma, and thus, left liver lobectomy was performed. On histological examination of the resected specimen, the tumor was found to be composed of uniform and small tumor cells with solid or trabecular growth fashion. On immunohistochemical staining, synaptophysin and chromogranin A positivity was noted, and the Ki-67 index was 14%. Finally, the tumor was diagnosed as a NET G2. Postoperatively, somatostatin receptor scintigraphy was performed to identify the primary site; however, no obvious primary site could not be identified, and thus a diagnosis of primary hepatic NET was made. Eighteen months postoperatively, the patient is alive without relapse. Preoperative diagnosis of primary hepatic NETs is difficult because NETs present various imaging findings and are rare. Moreover, no accurate preoperative diagnosis was reached in our case, suggesting the difficulty in the preoperative diagnosis of NETs.

[A Case with Three Resections of the Pulmonary Metastases of a Distal Bile Duct Carcinoma]

A 68-year-old man underwent a subtotal stomach-preserving pancreatoduodenectomy(SSPPD)for a distal bile duct carcinoma(BDC)pT3aN1M0, pStage ⅡB and adjuvant chemotherapy with gemcitabine. One year 7 months after the initial surgery, CT revealed a nodule with an increasing tendency in the left lung. As it was difficult to distinguish primary lung cancer from BDC lung metastasis, we performed a thoracoscopic left wedge resection. The histopathology of the resected specimen was BDC lung metastasis. In the follow-up with adjuvant chemotherapy with S-1 for 10 months, 2 nodules were found in the right lung, and we performed thoracoscopic right S6 segmentectomy. Eight months later, another nodule was found in the left lung, and we performed thoracoscopic left wedge resection. The histopathology was BDC lung metastasis for all the resected specimens. The patient is alive with no evidence of recurrence after 9 months of the latest surgery(4 years 11 months after the initial surgery). Although the standard treatment for metastatic recurrence of BDC is systemic chemotherapy, some cases treated with surgical resection had relatively good prognosis, such as the present case. Surgical resection might be feasible as a treatment option for metastatic recurrence of BDC.

Surgical outcomes of laparoscopic cholecystectomy for acute cholecystitis in elderly patients

INTRODUCTION

The clinical significance of laparoscopic cholecystectomy (LC) for acute cholecystitis in elderly patients aged 80 years or older has not been determined. This study aimed to investigate surgical outcomes of LC for acute cholecystitis in elderly patients compared to non-elderly patients.

METHODS

Patients who underwent urgent LC for acute cholecystitis were enrolled. Older (≥80 years) and younger patients (<80 years) were compared for perioperative factors to assess surgical outcomes of LC.

RESULTS

A total of 351 patients were included; 52 (14.8%) and 299 (85.2%) were categorized as older and younger, respectively. The older group had a significantly higher proportion of patients with concomitant physiological diseases than the younger group and a significantly higher ASA classification. No significant differences between the two groups were found in operation time, intraoperative blood loss, or conversion rate to open surgery. Incidence of postoperative complications and duration of postoperative hospital stay also were not significantly different between the two groups.

CONCLUSION

Surgical outcomes of LC for acute cholecystitis in older patients are comparable to those in younger patients, which confirms the feasibility of LC for acute cholecystitis in elderly patients.

[A Rare Case of Adenosquamous Carcinoma in the Liver with Hepatolithiasis]

This report describes a case of primary adenosquamous carcinoma of the liver with hepatolithiasis. A 70's man was followed up at a clinic for hepatolithiasis, gallbladder stone, and dilatation of the intrahepatic duct. He visited our hospital for computed tomography(CT)examination. CT showed a 30mm diameter low-density mass in the S2 liver and dilatation of the intrahe- patic duct filled with hepatolithiasis. Blood examination showed elevated levels of tumor markers(CEA 8.0 ng/mL, CA19-9 19,196 U/mL). We diagnosed the tumor as cholangiocellular carcinoma(cT2N1M0, cStage ⅣA)with hepatolithiasis and performed left hepatectomy and lymphadenectomy. In the specimen, a 39×22mm diameter solid tumor was detected and the intrahepatic duct was filled with haptolithiasis. Pathologically, a mixture of adenocarcinoma and squamous cell carcinoma was observed adjacent to the bile duct. Accordingly, a diagnosis of adenosquamous carcinoma was made(pT3N0M0, pStage Ⅲ). Multiple liver metastases were detected 8 months after the operation, and chemotherapy was started. He remains alive 11 months after the operation. We experienced a rare case of adenosquamous carcinoma in the liver with hepatolithiasis.

[A Resected Case of Reactive Lymphoid Hyperplasia of the Liver Preoperatively Diagnosed as Hepatocellular Carcinoma]

A60s woman was followed-up regularly for primary biliary cholangitis and a solitary enlarging hepatic mass in the S6 segment of her liver was discovered by ultrasonography. We diagnosed the mass as hepatocellular carcinoma by contrast ultrasonography, contrast computed tomography, and ethoxbenzyl magnetic resonance imaging and laparoscopic partial hepatectomy of S6 segment was performed. The resected specimen was histopathologicaly diagnosed as liver-reactive lymphoid hyperplasia(RLH). The patient is alive without recurrence 17 months after the surgery. Although liver RLH is a rare disease, it should be considered in the differential diagnosis of small liver tumors.

[Clinicopathological Study of 15 Cases of Primary Duodenal Cancer]

There have been few reports discussing treatments for primary duodenal cancer. In this study, 15 cases of primary duodenal cancer that were treated by curative resection in our hospital between April 2005 and December 2017 were analyzed to study appropriate operative procedures. Prognostic analysis revealed that the median of relapse-free survival and overall survival were 49 months and 74 months, respectively. The 5-year survival rate was 47%. On univariate analysis of relapse-free survival, lymph node metastasis(p<0.01)and post-operative adjuvant therapy(p=0.02)were significant independent prognostic factors. Analysis of the relationship between lymph node metastasis and the depth or location of tumors suggested that pancreaticoduodenectomy with lymph node dissection should be performed to achieve radical resection, since there were some cases that involved lymph node metastasis around the pancreatic head or hepatoduodenal ligament.

[A Resected Case of Gallbladder Cancer Concomitant with Xanthogranulomatous Cholecystitis with Difficulty in Preoperative Diagnosis]

A 78-year-oldman was referredto our hospital for right abdominal pain. The patient was diagnosedwith xanthogranulomatous cholecystitis(XGC)at the gallbladder fundus and adenomyomatosis(ADM)at the gallbladder neck. Because malignancy was undeniable, laparotomy was performed. Frozen section examination of the excised whole-layer gallbladder revealed cancer cells at the gallbladder neck and cystic duct. Therefore, additional gallbladder bed resection, extrahepatic bile duct resection, and lymphadenectomy were performed. The final diagnosis, based on the histopathological examination of all resected specimens, was gallbladder adenocarcinoma(T3aN0M0, Stage ⅢA). ADM was not observedat the same sites as the adenocarcinoma. The fundus lesion was diagnosed as XGC. Here, we report our rare case of XGC coexisting with gallbladder cancer.

[A Case of Resection of a Mucinous Cystic Neoplasm of the Liver]

A 55 -year-old woman presented at our hospital in 2017. In 2014, a large cyst had been detected in her liver by ultrasonography, and she was followed up at a clinic. Abdominal computed tomography(CT)revealed a large multilocular cystic tumor measuring 12 cm in diameter in the left lobe of the liver. Although no solid component was identified in the tumor, the cystic tumor was increasing in size, and the serum level of CA19-9 was elevated. Under a preoperative diagnosis of mucinous cystic neoplasm(MCN)of the liver, we performed extended left liver lobectomy. There were no postoperative complications. Histopathological examination of the resected specimen revealed low-grade intraepithelial neoplasia, and the epithelium covered an ovarian-type stroma. The ovarian-type stromal cells were immunoreactive for estrogen receptor and progesterone receptor. The definitive diagnosis of the tumor was MCN of the liver with low-grade intraepithelial neoplasia. Eight months after the surgery, the patient remains alive without any recurrence.

[A Case of Successful Control of Advanced Duodenal Cancer with Liver Metastasis Receiving Paclitaxel Chemotherapy and Potential Radical Resection]

We report a case of successful control of advanced duodenal cancer with paclitaxel chemotherapy. A woman in her 70s with epigastralgia was diagnosed with hemorrhagic duodenal ulcer upon upper gastrointestinal endoscopy. A type 3 tumor was found in the duodenal bulb upon upper gastrointestinal endoscopy and biopsy at our hospital. By contrast CT, we found wall hypertrophy of the duodenal bulb, lymph node metastasis, and liver metastasis and started chemotherapy. Four courses of SOX therapy were first administered. The wall hypertrophy of the duodenal bulb worsened, and new lesions appeared in the liver, so we diagnosed progressive disease. Next, 4 courses of wPTX therapy were administered. The wall hypertrophy of the duodenal bulb improved, and all liver metastatic lesions shrunk and became obscure. The reduction rate was 75%, so we diagnosed partial response. Accumulation in the primary tumor was observed on PET-CT, and the lymph node and liver metastases disappeared, so we considered radical curative resection. The patient underwent subtotal stomach preserving pancreatoduodenectomy, D2 lymph node dissection, reconstruction of the digestive tract by the modified CHILD method, partial hepatectomy, and Brawn's anastomosis. No cancer cells were found in the hepatectomized area. Paclitaxel chemotherapy may be useful for advanced duodenal cancer.

[A Resected Case of Lymph Node Metastasis at the Splenic Hilum from Lung Cancer Invading the Pancreas and Spleen]

A 72-year-old man received chemoradiotherapy for lung squamous cell carcinoma(T4N2M0, Stage Ⅲb). Nine months after the start of chemoradiotherapy, a 60 mm sized mass was identified in the spleen on abdominal CT. FDG-PET/CT examination revealed abnormal FDG accumulation in the tumor, and no obvious accumulation was observed in other sites. By endoscopic ultrasound-guided fine needle aspiration cytology, the tumor was diagnosed as splenic metastasis from lung cancer. Since the primary lung tumor was well controlled by the chemoradiotherapy and no metastatic lesions were found except in the spleen, laparoscopic excision of the splenic metastasis was planned. Since the tumor was suspected to have infiltrated the tail of the pancreas, laparoscopic distal pancreatectomy and splenectomy were performed. There were no severe postoperative complications. The resected tumor was histopathologically diagnosed as not splenic metastasis, but lymph node metastasis at the splenic hilum from lung cancer invading the pancreas and spleen. Brain metastasis and bone metastasis were observed 3 months postoperatively. He did not undergo any treatments for the metastatic lesions, and he died because of the cancer 11 months after the operation. This case suggests the clinical significance of surgical treatment for distant metastatic lesions from lung cancer.

[A Case of Intrahepatic Cholangiocarcinoma with Tumor Thrombus in the Left Portal Branch]

A 63-year-old man was referred to our hospital for detailed examinations and treatment of a hepatic tumor. Abdominal contrast-enhanced CT examination showed a huge mass measuring 12 cm in diameter with ring enhancement in the left liver lobe. The liver tumor was accompanied by a macroscopic tumor thrombus in the left portal branch. Under preoperative diagnosis of intrahepatic cholangiocarcinoma with portal vein tumor thrombus, left liver lobectomy, removal of the tumor thrombus, extrahepatic bile duct excision, and lymph node dissection were performed. Histopathological examination of the resected specimens revealed moderately differentiated adenocarcinoma concomitant with tumor thrombus in the left portal branch. Adjuvant chemotherapy with S-1 was administered. However, 3 months after the surgery, CT examination revealed postoperative recurrences in the liver, lung, and bone. Systemic chemotherapy with gemcitabine and cisplatin was administered with radiotherapy for the bone metastasis. However, the chemotherapy was not effective, and 6 months after surgery, he died of the cancer. There have been few reports of cases with ICC accompanied by a macroscopic portal vein tumor thrombus. Based on the reported cases and the present case, prognosis of the disease seems very poor.

[A Case of Locally Advanced Gastric Cancer Treated with Chemoradiotherapy before Surgical Resection]

A 70-year-old woman presented to our hospital because of stomach pain. She was diagnosed as having clinical Stage ⅢC gastric cancer with invasion into the pancreas and treated with S-1+oxaliplatin(SOX)as neoadjuvant therapy, after palliative radiotherapy for tumor bleeding. After 4 courses of SOX therapy and 7 courses of S-1 therapy, the tumor size reduce and the invasion into the pancreas disappeared. Subsequently, she underwent distal gastrectomy. The pathological diagnosis was ypStage ⅢB, with no findings of tumor invasion into the pancreas. As of 1 year 9 months after the surgery, no metastasis or recurrence was observed.

[A Case of Unresectable Advanced Gastric Neuroendocrine Cell Carcinoma Treated with Nivolumab]

A 69-year-old man was administered S-1/oxaliplatin/trastuzumab as induction chemotherapy for advanced gastric cancer (cT4b[liver, pancreas], N2M1(H1P0CYX), cStage IV). After 4 courses, because contrast-enhanced computed tomography showed remarkable reduction of the tumor, distal gastrectomy, partial hepatectomy, and radiofrequency ablation for the liver metastasis were performed. The patient was histopathologically diagnosed with gastric neuroendocrine carcinoma(NEC). S- 1/oxaliplatin/trastuzumab was continued after surgery; however, recurrence in the remnant liver was observed after 4 cours- es. For recurrence, cisplatin/irinotecan as first-line and paclitaxel/ramucirumab as second-line treatment were administered, but progression of liver metastasis and ascites due to peritoneal dissemination were observed. As third-line treatment, nivolumab was initiated. Ascites decreased after 3 courses, but after 2 more courses, progression of ascites, liver recurrence, and multiple metastasis in the lumbar vertebra were observed.

A case of intraductal papillary-mucinous neoplasm of the pancreas penetrating into the stomach and spleen successfully treated by total pancreatectomy

Background

Intraductal papillary-mucinous neoplasms (IPMNs) are potentially malignant intraductal epithelial neoplasms that sometimes penetrate into other organs. To the best of our knowledge, no report has yet described a case with penetration into the spleen. We recently encountered a case of IPMN with penetration of the stomach and spleen that was successfully treated by total pancreatectomy.

Case presentation

A 70-year-old female visited our hospital with a complaint of fever and abdominal pain. Contrast-enhanced computed tomography (CT) revealed dilatation of the main pancreatic duct in the entire pancreas and penetration into the stomach and spleen. Upper gastrointestinal endoscopy revealed mucin extruding from four openings of the fistula in the stomach. No malignancy was detected based on cytology of the mucin. Inflammation markers and tumor markers (CEA, CA19–9) were elevated in the blood. The pre-operative diagnosis was IPMN of main pancreatic duct type penetrating into the stomach and spleen. A total pancreatectomy and splenectomy were performed, combined with distal gastrectomy including resection of the fistulas between the pancreas and stomach. No postoperative complications were noted. Histopathological examination of the resected specimen revealed atrophy of the pancreatic parenchyma, and the main duct of the pancreas was filled with mucin. Mucin-producing malignant tumor cells were detected in the epithelium of the main pancreatic duct with no signs of invasion. No malignancy was found at the fistulas between the pancreas and stomach or spleen. The patient was finally diagnosed with non-invasive intraductal papillary-mucinous carcinoma (IPMC) of main pancreatic duct type. Mechanical penetration was suspected as a mechanism of the penetration. The patient remained disease-free without evidence of recurrence more than 15 months after the operation.

Conclusion

Though IPMNs sometimes penetrate into other adjacent organs, penetration into two organs, including the spleen, is rare. The rare case of IPMC penetrating into the stomach and spleen presented here was treated successfully by total pancreatectomy.

Successful Endoscopic Treatment of Post-esophagectomy Refractory Reflux Using OverStitch: The First Clinical Case

Aims:

The reflux of duodeno-gastric contents into the remnant esophagus (gastric tube-esophageal reflux: GTER) is a significant issues in long-term esophageal cancer survivors after radical esophagectomy. We attempted endoscopic valve (funnel) creation for prevention for GTER using OverStitch endoscopic suturing system.

Methods:

The OverStitch was mounted onto a standard double-channel endoscope. Under general anesthesia, the funnel creation was attempted by placing semi-full thickness sutures on the gastric wall, at 3 cm distal to the primary esophago-gastric anastomosis. The postoperative outcomes were also evaluated.

Results:

In total, 4 sutures were needed and the operating time was 62 minutes without complication. The endoscopic and swallowing studies, as well as pH profile, were all improved postoperatively. The patient’s quality of life was dramatically improved with complete disappearance of night-time reflux in spine position.

Conclusions:

Endoscopic antireflux funnel creation was feasible and safe. This procedure may become a useful treatment for patients with severe GTER after esophagectomy.

[A Case Report of SOX Treatment for Primary Duodenal Carcinoma with Liver Metastasis]

We report a case of effective S-1 plus oxaliplatin (SOX) treatment for duodenal cancer with liver metastases. The patient was a 70-year-old female diagnosed with duodenal carcinoma that was unresectable because of liver metastasis(cT4N1M1, cStage IV in UICC 7th). She received SOX treatment(100mg/m / 2 of oxaliplatin on day 1 combined with 40 mg/day of S-1 twice daily on days 1-14, was repeated every 3 weeks). After 4 courses, a partial response was confirmed by computed tomography and no severe adverse events were observed. However, during the 5th courses, several new liver metastases were observed, so we changed to weekly paclitaxel treatment. This case suggests that SOX treatment may be an effective chemotherapy for advanced primary duodenal carcinoma.

Ruptured Cystic Artery Pseudoaneurysm Successfully Treated with Urgent Cholecystectomy: A Case Report and Literature Review

Patient: Male, 90

Final Diagnosis: Ruptured cystic artery pseudoaneurysm

Symptoms: Epigastric pain • Fever

Medication: —

Clinical Procedure: Open cholecystectomy

Specialty: Gastroenterology and Hepatology

[A Case of Small-Sized Acinar Cell Carcinoma of the Pancreas Resected by Laparoscopic Distal Pancreatectomy]

A 81-year-old woman was referred to our hospital for a stomach pain. Abdominal enhanced CT scan showed a pancreatic hypovascular tumor 10mm in size. Abnormal FDG uptake was found on the tumor at FDG/PET-CT examination. The tumor was identified also at endoscopic ultrasonography, and the endoscopic ultrasound-guided fine needle aspiration biopsy of this tumor gave the diagnosis of pancreatic adenocarcinoma. Under the preoperative diagnosis, laparoscopic distal pancreatectomy was performed. There were no postoperative complications. Histopathological examination of the resected tumor revealed acinar cell carcinoma of the pancreas, not pancreatic adenocarcinoma. The patient is alive without any postoperative recurrences 1 year after the pancreatectomy.

[A Case in Which S-1/Oxaliplatin(SOX)/Trastuzumab Therapy Was Effective for Unresectable HER2 Positive Advanced Gastric Cancer and Radical Resection Could Be Performed]

The case was a 70s-year-old man. In July 2016, he was admitted to our hospital with a complaint of epigastralgia. Upper gastrointestinal endoscopy revealed type 3 advanced gastric cancer in the vestibule, directly infiltrating the pancreas and the left lobe of the liver to form an abscess, and swelling of the aortic lymph node and multiple liver metastases were observed. The cancer was diagnosed as cT4b(liver/pancreas), N2M1(H1P0CYX), cStage IV and diagnosed it as a chemotherapy policy. We initiated SOX plus trastuzumab therapy from August 2016. After 4 courses, the primary tumor shrunk significantly and invasion to the pancreas/liver had disappeared. Furthermore, the periarterial lymph node and multiple liver metastases were obscured(chemotherapy effect judgment: PR). With a diagnosis of ycT4aN1MX(HXP0CYX), in December 2016, we performed a pyloric side gastrectomy D2(+No.16)dissection and partial resection of the liver(S3, S4, S6), liver RFA(S4, S6, S7). Due to recent progress in chemotherapy and multidisciplinary therapy, there is a possibility that radical resection may be carried out for advanced gastric cancer, which was previously unresectable, by performing a treatment with surgery in mind.

[A Case of a Hepatic Inflammatory Pseudotumor Difficult to Distinguish from Metastatic Liver Cancer and Potentially Caused by Colon Diverticula]

This report describes the case of an 85-year-old man who underwent left hemicolectomy for descending colon cancer and hepatic segmentectomy for metastatic liver cancer. Seven years after the liver surgery, an abdominal CT scan revealed a tumor in the remnant liver. He also presented with colon diverticula in the ascending colon, which was located close to the liver tumor. With a preoperative diagnosis of metastatic liver cancer, the tumor was resected with S8 segmentectomy. Histopathological examination of the resected tumor revealed a hepatic inflammatory pseudotumor, not metastatic liver cancer. The present case showed the difficulty of preoperatively diagnosing inflammatory pseudotumors. Furthermore, it is noted in the case that since the liver tumor was located close to the colon diverticula in the ascending colon, the diverticula was potentially associated with the formation of hepatic inflammatory pseudotumor.

Feasibility of laparoscopic cholecystectomy in patients with cerebrospinal fluid shunt

INTRODUCTION

Previous reports of laparoscopic surgery in patients with cerebrospinal fluid (CSF) shunts for intracranial hypertension described shunt-related complications. Thus, the shunts have been considered a contraindication for laparoscopic procedures. However, with the implementation of recent improvements in surgical techniques, perioperative management, and shunt technology, laparoscopic surgery may now be safe in cases with shunts. The aim of the present study was to examine the safety of such procedures based on our own experiences with laparoscopic surgery in patients with CSF shunts.

METHODS

A total of 582 patients underwent laparoscopic cholecystectomy for gallbladder disease at our institute during the study period. Among these patients, four (0.7%) had a CSF shunt at the time of laparoscopic cholecystectomy. We retrospectively investigated the clinical characteristics of these four cases.

RESULTS

Two patients had ventriculoperitoneal shunts, and two patients had lumboperitoneal shunts. Based on the advice of consulted neurosurgeons, the shunt catheter was clamped during pneumoperitoneum in three of the four cases, and the catheter was left unclamped in the remaining case because it was judged to be occluded. Laparoscopic cholecystectomy was performed under pneumoperitoneum pressure of 8 mmHg. All four cases experienced an uneventful postoperative course, with no shunt-associated complications.

CONCLUSION

Analysis of our current cases suggests the safety of laparoscopic cholecystectomy in cases with CSF shunts.

[Case of Adenocarcinoma with Neuroendocrine Carcinoma Component in the Gallbladder]

A 73-year-old man visited our hospital complaining of abdominal pain. An abdominal CT scan revealed diffuse wall thickening of the gallbladder with a gallstone. Urgent laparoscopic cholecystectomy was performed with the diagnosis of acute cholecystitis. Histopathological examination indicated adenocarcinoma with a small neuroendocrine carcinoma component invading the subserous layer. Additional gallbladder bed resection and lymphadenectomy were performed. The final pathological diagnosis was adenocarcinoma with NEC, pT2N0M0, pStage II . The patient is alive without any recurrence 7 months after the last surgery.

Pancreatic intraductal tubulopapillary neoplasm with associated invasive cancer successfully treated by total pancreatectomy: A case report

A 74-year-old male was admitted to Departments of Surgery, Toyonaka Municipal Hospital (Osaka, Japan) for treatment of a pancreatic tumor. Contrast enhanced computed tomography (CT) revealed a mass with small cystic lesions in the pancreatic head and body. Fluorodeoxyglucose-positron emission tomography/CT revealed an abnormal uptake of fluorodeoxyglucose, corresponding to the mass lesions. Upper gastrointestinal endoscopy revealed rough mucosa near the opening of the accessory pancreatic duct, and the mucosa biopsy exhibited adenocarcinoma with no mucin observed. The preoperative diagnosis was pancreatic intraductal tubulopapillary neoplasm (ITPN) with cancerous lesions, and a total pancreatectomy with splenectomy was performed. The resected tissue specimen revealed a solid tumor occupying the entire pancreas with intraductal growth into the main pancreatic duct. Histological examination revealed high-grade dysplastic cells in a tubulopapillary growth pattern without overt mucin production beyond the pancreatic duct. Immunohistochemical staining analysis of the tumor was positive for cytokeratin (CK)7, CK19 and mucin (MUC)1, and negative for MUC2, MUC5AC, MUC6 and caudal type homeobox 2. The tumor was finally diagnosed as pancreatic ITPN with associated invasive cancer. The patient remains well without evident recurrence nine months post-surgery. ITPN is a rare type of epithelial neoplasm of the pancreas, and is characterized by intraductal tubulo-papillary growth, ductal differentiation, limited intracellular mucin production, and cellular dysplasia. The present case report may contribute to improved understanding of how to effectively treat patients with ITPN.

Gene expression levels of gamma-glutamyl hydrolase in tumor tissues may be a useful biomarker for the proper use of S-1 and tegafur-uracil/leucovorin in preoperative chemoradiotherapy for patients with rectal cancer

Purpose

Preoperative chemoradiotherapy (CRT) using 5-fluorouracil (5-FU)-based chemotherapy is the standard of care for rectal cancer. The effect of additional chemotherapy during the period between the completion of radiotherapy and surgery remains unclear. Predictive factors for CRT may differ between combination chemotherapy with S-1 and with tegafur-uracil/leucovorin (UFT/LV).

Methods

The subjects were 54 patients with locally advanced rectal cancer who received preoperative CRT with S-1 or UFT/LV. The pathological tumor response was assessed according to the tumor regression grade (TRG). The expression levels of 18 CRT-related genes were determined using RT-PCR assay.

Results

A pathological response (TRG 1-2) was observed in 23 patients (42.6%). In a multivariate logistic regression analysis for pathological response, the overall expression levels of four genes, HIF1A, MTHFD1, GGH and TYMS, were significant, and the accuracy rate of the predictive model was 83.3%. The effects of the gene expression levels of GGH on the response differed significantly according to the treatment regimen. The total pathological response rate of both high-GGH patients in the S-1 group and low-GGH patients in the UFT/LV group was 58.3%.

Conclusion

Additional treatment with 5-FU-based chemotherapy during the interval between radiotherapy and surgery is not beneficial in patients who have received 5-FU-based CRT. The expression levels of four genes, HIF1A, MTHFD1, GGH and TYMS, in tumor tissues can predict the response to preoperative CRT including either S-1 or UFT/LV. In particular, the gene expression level of GGH in tumor tissues may be a useful biomarker for the appropriate use of S-1 and UFT/LV in CRT.

Endoscopic anti-reflux valve for post-esophagectomy reflux: an animal study

Background and study aims: Gastric reflux into the remnant esophagus after subtotal or partial esophagectomy is associated with impairment in patient quality of life. We evaluated the feasibility, safety, and potential effectiveness of a novel procedure using a new endoscopic suturing device to create an anti-reflux valve (funnel) in pigs after esophagectomy with gastric tube reconstruction. Methods: The endoscopic procedure was performed in four pigs using a semi-full-thickness endoscopic suturing system (OverStitch; Apollo Endosurgery, Austin, Texas, USA). The operating time, funnel height, ratio of the height of the funnel to the diameter of the gastric tube, and adverse events associated with the procedure were evaluated. The "reflux angle" was measured morphologically and functionally during a reflux induction test, using contrast medium or artificial gastric fluid, by tilting the operating table gradually from a head up to a head down position. Reflux angles before and after funnel creation were compared. Results: The procedure was successful in all four animals. The median operating time was 43 minutes, and the median funnel height was 17 mm (56.7 % of gastric tube diameter). There were no adverse events associated with the procedure. The reflux angle was lower after the procedure compared with before in both morphological and functional assessments in all four cases. Conclusions: Endoscopic anti-reflux funnel creation using OverStitch was feasible, safe, and potentially effective.

[A Resected Case of Intraductal Pupillary Mucinous Neoplasm of the Pancreas Characterized by Recurrence in the Remnant Pancreas and Multiple Malignant Neoplasms in Other Organs]

A 74-year-old man underwent pancreaticoduodenectomy for intraductal pupillary mucinous neoplasm(IPMN)of the pancreatic head. Histopathological examination of the specimen revealed non-invasive intraductal papillary mucinous carcinoma( IPMC). Two years after surgery, recurrent IPMN developed in the remnant pancreas, and a liver tumor was identified in S8 of the liver. The patient underwent total pancreatectomy of the remnant pancreas and partial resection of S8. These tumors were histopathologically diagnosed as invasive IPMC and hepatocellular carcinoma, respectively. Five years after the resec- tions, another liver tumor was identified in S4/3 of the liver, and partial resection of S4/3 was performed. The tumor was histopathologically identified as cholangiocellular carcinoma. Seven months after the last surgery, the patient remains in good health without any recurrences. IPMN is characterized by IPMN recurrence in the remnant pancreas and malignant neoplasms in other organs, and the present case showed both characteristics. The case suggested the importance of postoperative follow-up of IPMN patents with regard to the characteristics of IPMN.

[Afferent Loop Syndrome after Hepatobiliary and Pancreatic Surgery Successfully Treated with Percutaneous Drainage]

We report 2 cases where afferent loop syndrome after hepatobiliary and pancreatic surgery was successfully treated with percutaneous drainage. Case 1: A 74-year-old man who had undergone pancreaticoduodenectomy for pancreatic cancer presented with cholangitis, obstructive jaundice, and dilatation of the elevated jejunum. These conditions were attributed to obstruction of the elevated jejunum on the anal side due to peritoneal dissemination. Subsequently, percutaneous transhepatic biliary drainage was performed, and the dilated jejunum was drained through the approach route. Case 2: A 71-year-old woman who had undergone left hepatectomy for hilar bile duct cancer presented with peritoneal dissemination. Owing to the dissemination, the elevated jejunum was obstructed, resulting in its dilatation on the oral side. Percutaneous drainage of the dilated jejunum was directly performed. Percutaneous drainage was effective in both the abovementioned cases, and no symptoms related to the obstruction were observed until the death of the patients because of primary cancer. This suggested that percutaneous drainage may be an effective treatment option for afferent loop syndrome after hepatobiliary and pancreatic surgery.

[Resection of Hepatocellular Carcinoma with Synchronous Bilateral Adrenal Metastases]

A 59-year-old man was admitted to our hospital with liver dysfunction. Examinations revealed a huge liver tumor in the right hepatic lobe and a mass in each adrenal gland. The preoperative diagnosis was hepatocellular carcinoma(HCC)with synchronous bilateral adrenal metastases. The patient underwent right hepatic lobectomy, cholecystectomy, and bilateral adrenalectomy. Histopathological examination of the specimens confirmed the diagnosis of HCC with synchronous bilateral adrenal metastases. After surgery, he received steroid replacement therapy and had a favorable clinical course without complications. Six months after surgery, the patient has experienced no recurrence and is being followed up on an outpatient basis. Although further postoperative follow-up is necessary, the findings of this case suggested a positive oncological impact of surgical resection for HCC and synchronous bilateral adrenal metastases.

[A Case of Adenocarcinoma of the Vater Papilla Treated with Pancreatoduodenectomy after Hepaticojejunostomy for Prior Adenocarcinoma of the Gallbladder]

A 77-year-old man was diagnosed with acute cholecystitis and underwent laparoscopic cholecystectomy. Since adenocarcinoma in the gallbladder was detected by histopathological examination, he received additional resection for the carcinoma: partial hepatectomy(S4a, S5), extrahepatic bile duct resection, and hepaticojejunostomy. Five years after the surgery, he was diagnosed with adenocarcinoma of the Vater papilla. Pancreatoduodenectomy was performed. During the surgery, the prior hepaticojejunostomy and jejunojejunostomy were preserved, and the gastrointestinal tract was cut at the stomach and jejunum 5 cm from the Treitz ligament. A postoperative pancreatic fistula developed, but it resolved. The method of reconstruction in this case has the advantage of not only a smaller number of resections and anastomoses of the gastrointestinal tract but also a better preservation of blood flow in the jejunum compared to other methods reported in previous studies.

[Clinicopathological Study of Incidental Gallbladder Cancer Diagnosed after Laparoscopic Cholecystectomy]

The aim of this study was to clarify the clinicopathological characteristics of incidental gallbladder cancer(iGBC)diagnosed after laparoscopic cholecystectomy. A total of 33 patients diagnosed with iGBC were enrolled in this study, and their clinicopathological characteristics were investigated. Preoperative diagnoses were as follows: cholelithiasis in 16 patients, polypoid lesions in 8, cholecystitis in 7, and adenomyomatosis in 2. Depth of mural invasion of iGBC was M in 14 cases, MP in 3, SS in 12, and deeper than SS in 4. M/MP cases with negative margins were followed up, and cases with SS/deeper than SS underwent additional resection. Prognosis of these patients with iGBC was not significantly different from that of non-iGBC (niGBC)patients. There was no significant difference in R2 resection rate between iGBC and niGBC with SS/deeper than SS. Intriguingly, peritoneal dissemination was identified on additional resection in 1 case that had intraoperative bile leakage at the prior laparoscopic cholecystectomy. Port-site recurrence was found in 2 iGBC cases. These results suggested that the treatment strategy for iGBC is acceptable. However, considering the existence of cases with peritoneal dissemination or portsite recurrence, the possible presence of iGBC should be kept in mind at the initial laparoscopic cholecystectomy.

Two FOXP3(+)CD4(+) T cell subpopulations distinctly control the prognosis of colorectal cancers

CD4(+) T cells that express the forkhead box P3 (FOXP3) transcription factor function as regulatory T (Treg) cells and hinder effective immune responses against cancer cells. Abundant Treg cell infiltration into tumors is associated with poor clinical outcomes in various types of cancers. However, the role of Treg cells is controversial in colorectal cancers (CRCs), in which FOXP3(+) T cell infiltration indicated better prognosis in some studies. Here we show that CRCs, which are commonly infiltrated by suppression-competent FOXP3(hi) Treg cells, can be classified into two types by the degree of additional infiltration of FOXP3(lo) nonsuppressive T cells. The latter, which are distinguished from FOXP3(+) Treg cells by non-expression of the naive T cell marker CD45RA and instability of FOXP3, secreted inflammatory cytokines. Indeed, CRCs with abundant infiltration of FOXP3(lo) T cells showed significantly better prognosis than those with predominantly FOXP3(hi) Treg cell infiltration. Development of such inflammatory FOXP3(lo) non-Treg cells may depend on secretion of interleukin (IL)-12 and transforming growth factor (TGF)-β by tissues and their presence was correlated with tumor invasion by intestinal bacteria, especially Fusobacterium nucleatum. Thus, functionally distinct subpopulations of tumor-infiltrating FOXP3(+) T cells contribute in opposing ways to determining CRC prognosis. Depletion of FOXP3(hi) Treg cells from tumor tissues, which would augment antitumor immunity, could thus be used as an effective treatment strategy for CRCs and other cancers, whereas strategies that locally increase the population of FOXP3(lo) non-Treg cells could be used to suppress or prevent tumor formation.

Abstract A169: NY-ESO-1 protein cancer vaccine with TLR 3 and 4 agonists

NY-ESO-1 is expressed in wide range of human malignancies expect testis in normal tissues and induces spontaneous antibody in patients with cancers expressing NY-ESO-1. Because of its unique expression and high immunogenicity, NY-ESO-1 is promising as a target of cancer vaccine. We have conducted serial clinical trials with the NY-ESO-1 protein since 2004 and antigen-specific immune responses were observed in most of patients immunized. Some patients showed feasible clinical responses however they were limited and novel immune modulators which could make NY-ESO-1 protein vaccination effective are needed. Recently, stimulation through the Toll-like receptors (TLRs) enhance the induction of antigen-specific immune responses upon cancer vaccine has become apparent. In this study, we conducted a phase I cancer vaccine clinical trial using NY-ESO-1 protein combined with Poly ICLC and Picibanil OK-432 as TLR 3 and 4 agonist, respectively.

This trial was designed to evaluate the safety, induction of immune response and clinical response. Patients with advanced cancers expressing NY-ESO-1 were eligible. 200μg NY-ESO-1 protein mixed with Montanide in combination of Poly ICLC and/or Picibanil OK-432 was administered subcutaneously once every 2 weeks in six times. Seven patients with esophageal cancer, three with gastric cancer, two with lung cancer, two with ovarian cancer and one with malignant melanoma were enrolled in four groups, i) NY-ESO-1 protein alone (n=3), ii) NY-ESO-1 protein with OK-432 (n=3), iii) NY-ESO-1 protein with Poly ICLC (n=3), iv) NY-ESO-1 protein with OK-432 and Poly ICLC (n=6). All patients developed an injection-site reaction and fever (grade1 or 2) but no severe adverse events related to the drug were observed. An increase in the NY-ESO-1 antibody response was observed in all patients after vaccination. Earlier induction and higher frequency of NY-ESO-1 responsible T cells were observed in patients immunized with Poly ICLC than those without Poly ICLC. NY-ESO-1 protein vaccine with Poly ICLC and OK432 was safe and antigen-specific immune responses were induced in all patients. TLR agonists would be useful and effective immune modulators for cancer vaccines.

Citation Format: Tomohira Takeoka, Hirotsugu Nagase, Yasuhiro Miyazaki, Tsuyoshi Takahashi, Yukinori Kurokawa, Tomoki Makino, Makoto Yamasaki, Shuji Takiguchi, Masaki Mori, Yuichiro Doki, Hisashi Wada. NY-ESO-1 protein cancer vaccine with TLR 3 and 4 agonists. [abstract]. In: Proceedings of the CRI-CIMT-EATI-AACR Inaugural International Cancer Immunotherapy Conference: Translating Science into Survival; September 16-19, 2015; New York, NY. Philadelphia (PA): AACR; Cancer Immunol Res 2016;4(1 Suppl):Abstract nr A169.

Inhibition of opioid systems in the hypothalamus as well as the mesolimbic area suppresses feeding behavior of mice

Opioid receptors, especially μ-opioid receptors, in the ventral tegmental area (VTA) and nucleus accumbens (NAcc) are reported to regulate food motivation. However, the roles of μ-, δ- and κ-opioid receptors are not fully understood. Moreover, since μ-, δ- and κ-opioid receptors are reported to distribute in the hypothalamus, these receptors in the hypothalamus might regulate feeding behavior. Thus, the present study investigated the role of μ-, δ- and κ-opioid receptors in the VTA, the NAcc and the hypothalamus in the regulation of feeding behavior. Male ICR mice were subjected to a feeding test after food deprivation for 16h. The mRNA levels of proopiomelanocortin (POMC), preproenkephalin (PENK) and prodynorphin (PDYN), the precursors of endogenous opioid peptides, were measured by reverse transcription-polymerase chain reaction (RT-PCR). The systemic injection of non-selective (naloxone) and selective μ (β-funaltrexamine; β-FNA), δ (naltrindole) and κ (norbinaltorphimine; norBNI) opioid receptor antagonists markedly reduced food intake. In contrast, the systemic injection of preferential μ (morphine), selective δ (KNT-127) and κ (U-50,488) opioid receptor agonists did not change food intake. The mRNA levels of POMC, PENK and PDYN were decreased in the hypothalamus and the midbrain after food deprivation, whereas the mRNA levels of PENK and PDYN, but not POMC, were decreased in the ventral striatum. The injection of naloxone into the NAcc, VTA and lateral hypothalamus (LH), but not the ventromedial nucleus of the hypothalamus, significantly decreased food intake. The injection of β-FNA and naltrindole into the LH, but not the VTA or NAcc, decreased food intake. The injection of norBNI into the LH and VTA, but not the NAcc, decreased food intake. These results indicate that μ-, δ- and κ-opioid receptors in the LH play a more important role in the regulation of feeding behavior than those receptors in the VTA and the NAcc.