Covered self-expandable metallic stent versus plastic stent for preoperative endoscopic biliary drainage in patients with pancreatic cancer: a multi-center retrospective cohort study

BACKGROUND

Expanding indications for neoadjuvant chemotherapy (NAC) for resectable pancreatic cancer prolong the period from diagnosis to surgery. In resectable pancreatic cancer with malignant biliary obstruction (MBO), the biliary drainage method without any biliary events is ideally required to safely perform NAC as planned. Plastic stents (PS) have been traditionally used for preoperative biliary drainage; however, recently, covered self-expandable metallic stents (CSEMS) have emerged as a tool for preoperative biliary drainage.

AIMS

To compare CSEMS with PS for preoperative biliary drainage in the management of resectable pancreatic cancer with MBO.

METHODS

In this multicenter retrospective cohort study, we compared CSEMS with PS for preoperative biliary drainage in patients with pancreatic cancer at three tertiary care centers between 2008 and 2019.

RESULTS

Of the 120 enrolled patients, 45 underwent CSEMS and 75 underwent PS. No significant difference was observed in the basic characteristics between the groups. The rate of recurrent biliary obstruction (RBO) was significantly lower and the time to RBO was significantly longer in the CSEMS group. In multivariate analysis, CSEMS was an independent factor for a longer RBO. However, pancreatitis and cholecystitis were more common in the CSEMS group. The surgery-related adverse events were not significantly different between the two groups, except for longer surgery time and time to discharge in the CSEMS group.

CONCLUSIONS

CSEMS for preoperative endoscopic biliary drainage in patients with pancreatic cancer reduced RBO, although the risk for pancreatitis or cholecystitis could be increased.

Pseudocirrhosis after chemotherapy for gastric cancer with diffuse liver metastases: A case report

Pseudocirrhosis is a rare but important complication of metastatic cancer. We herein present the case of a patient with pseudocirrhosis occurring after a complete response to chemotherapy for metastatic gastric cancer was achieved. A 72-year-old man was diagnosed with gastric adenocarcinoma with multiple liver metastases. The patient's general condition was good, with an Eastern Cooperative Oncology Group performance status of 1. Chemotherapy with oxaliplatin and S-1 was initiated and, after four cycles, the patient noticed sudden abdominal distension. Despite the marked regression of the liver metastases, massive ascites, segmental atrophy and esophageal varices developed, findings consistent with pseudocirrhosis. The patient achieved complete response for the primary and metastatic lesions. Following endoscopic ligation of the varices, he underwent subsequent chemotherapy with S-1 only and management of his ascites for 6 months. At 12 months after initial chemotherapy, the patient appeared to be disease-free. In conclusion, clinicians should be aware of the possibility of pseudocirrhosis in cases of cancer metastasis to the liver, including metastatic gastric cancer.

Th1 polarization in the tumor microenvironment upregulates the myeloid-derived suppressor-like function of macrophages

Here, we investigated the effect of Th1 polarization in the tumor microenvironment (TME) on tumor-associated macrophage (TAM) maturation and activation. In our immunotherapy mouse model, with a Th1-dominant TME, tumors regressed in all cases, with complete regression in 80% of the cases. Monocyte-derived dendritic cells and activated CD4⁺ and CD8⁺T-cells increased in the tumor-draining lymph node, and correlated with each other in the therapeutic model. However, the cytotoxicity of tumor-infiltrating CD8⁺T-cells was slightly inhibited, whereas the number of T-cells significantly increased. Moreover, the number of TAMs increased; their maturation was inhibited; and nitrotyrosine (NT) production, as well as iNOS and arginase I expression, was increased, suggestive of the myeloid-derived suppressor cell-like immunosuppressive function of TAMs. IFN-γ knockout in the therapeutic model decreased NT production and induced macrophage maturation. Hence, Th1 polarization in the IFN-γ-dominant condition induces T-cell immune responses; however, it also enhances the immunosuppressive activity of TAMs.

[Therapeutic Effect and Adverse Events of Ramucirumab in Patients with Gastric Cancer in Our Hospital]

From January 2016 through December 2017, 18 patients received paclitaxel plus ramucirumab combination therapy and 1 patient received ramucirumab monotherapy. Thus, a total of 19 patients were analyzed in terms of both therapeutic effect and adverse events. The response evaluation of the targeted lesion was as follows; CR: 0, PR: 1, SD: 16, PD: 2. The median of overall survival and progression-free survival of the combination therapy was 9.9 months and 4.2 months, respectively. Although more than half of the patients were enforced after tertiary therapy in our department, the therapeutic effect of paclitaxel plus ramucirumab combination therapy was considerably satisfactory. Neutropenia as an adverse event was observed in 13(68.4%)out of 19 patients, and 8 patients(42.1%)had neutropenia greater than Grade 3. Non -hematologic toxicity was observed in 17 cases(89.5%), and anorexia, nausea, diarrhea, dysgeusia, peripheral neuropathy, hair loss, and fatigue were determined to be either Grade 1 or 2. Alternatively, 1 patient developed Grade 3 interstitial pneumonia, and 3 patients(15.8%)had complicated Grade 3 high blood pressure. Only 2 patients who had severe adverse events, one was interstitial pneumonia and the other was high blood pressure, discontinued paclitaxel plus ramucirumab combination therapy.

Endoscopic duodenal stent versus surgical gastrojejunostomy for gastric outlet obstruction in patients with advanced pancreatic cancer

BACKGROUND

Malignant gastric outlet obstruction (GOO) often develops in patients with advanced pancreatic cancer (APC). It is not clear whether endoscopic duodenal stenting (DS) or surgical gastrojejunostomy (GJJ) is preferable as palliative treatment.

AIMS

To compare the efficacy and safety of GJJ and DS for GOO with APC.

METHODS

Consecutive 99 patients who underwent DS or GJJ for GOO with APC were evaluated. We compared the technical and clinical success rates, the incidence of adverse event (AE), the time to start chemotherapy and discharge and survival durations between DS and GJJ. Prognostic factors for overall survival (OS) were investigated on the multivariate analysis.

RESULTS

GOO was managed with GJJ in 35 and DS in 64. The technical and clinical success rates were comparable. DS was associated with shorter time to start oral intake and earlier chemotherapy start and discharge. No difference was seen in the early and late AE rates. Multivariate analyses of prognostic factors for OS showed that performance status ≧2, administration of chemotherapy, and presence of obstructive jaundice to be significant factors. There were no significant differences in survival durations between the groups, regardless of the PS.

CONCLUSIONS

There were no significant differences in the technical and clinical success and AE rates and survival duration between DS and GJJ in management of GOO by APC. DS may be a preferable option over GJJ given that it will lead to an earlier return to oral intake, a shortened length of hospital stay, and finally an earlier referral for chemotherapy.

[A Case of Stage IV Gastric Cancer Curative Resection by Conversion Therapy]

We experienced a case of curative resection as a multidisciplinary treatment for unresectable gastric cancer that attributed to peritoneal disseminations and direct invasion to other organs.Two courses of triplet chemotherapy(DCS therapy)were performed under enteral stent placement and nasoenteral nutrition for direct infiltration into the transverse colon with entire circumference stenosis.Distal gastrectomy and right hemicolectomy were performed as conversion therapy, and R0 resection was achieved.After the operation, S-1 as adjuvant chemotherapy was performed and there has been no relapse survival for 13 months since the operation.From this case, it seems that conversion therapy plays an important role in prognosis extension as a treatment strategy for Stage IV gastric cancer.

Effective Timing of Surgical Resection of Colorectal Cancer Liver Metastases During Chemotherapy

BACKGROUND/AIM

The aim of the present study was to further develop our previous study on c-Met expression in colorectal cancer and epithelial-mesenchymal transition (EMT) induced by hepatocyte growth factor (HGF), to investigate EMT in the process of liver metastases, and evaluate the effects of chemotherapy on EMT cells as a therapeutic strategy for colorectal liver metastasis.

MATERIALS AND METHODS

CT26 colon cancer cells were treated with 5-FU and oxaliplatin with or without HGF. The signaling pathway was evaluated by western blotting analysis, and drug resistance was evaluated by the MTT (3-(4,5-dimethyl-2-tetrazolyl)-2,5-diphenyl-2H tetrazolium bromide) assay.

RESULTS

Under pretreatment with HGF for 96 h, 5 μM and 10 μM of 5-FU mediated significant growth inhibition by 72.5±3.9% and 76.2±2.4%, respectively, compared to HGF alone, and by 105.1±2.8% and 103.5±2.9%, respectively, without HGF. The expression of E2F1 was decreased significantly to 50.5±3.8% after 24 hours by HGF with a reduction of both cyclin D1 to 52.1±7.0% and E to 73.7±3.8%. Thymidylate synthase was also decreased in a time-dependent manner to 80.6±2.0% after 24 h and to 52.7±1.5% after 96 h.

CONCLUSION

The presence of HGF was found to increase the 5-FU-induced death signal, JNK pathway, and inhibition of cell growth. As its mechanism, HGF was shown to decrease E2F-1 by reducing cyclin D or E by cell-cycle activation, resulting in inactivation of thymidylate synthase. The chemotherapeutic effect of 5-FU was increased in HGF- but not TGF-β-induced EMT.

Safety and feasibility of laparoscopic intersphincteric resection for a lower rectal tumor

The aim of the present study was to evaluate the short-term surgical outcomes of laparoscopic intersphincteric resection (ISR) for a lower rectal tumor in comparison with a case-control series of patients undergoing open ISR. Quality of life factors and anal function were also evaluated. Between July 2008 and April 2013, 103 patients with lower rectal cancer underwent laparoscopic surgery at the Surgical Oncology Department of Gifu University School of Medicine. A total of 25 patients with lower rectal cancer underwent ISR, and 19/25 patients who underwent laparoscopic ISR were compared with the control group of 6 patients who underwent open ISR. The technical feasibility and safety of ISR, and the short- and long-term outcomes following laparoscopic ISR were evaluated. Additional data associated with fecal incontinence conditions of the postoperative patients were evaluated using the Modified Fecal Incontinence Quality of Life scale. There was no recorded perioperative mortality, three complications were observed to occur in three patients and the morbidity rate was 15.8%. The postoperative complications detected included bleeding in one patient and ileus in two patients of the laparoscopic ISR group. The rate of severe complications of grade ≥3a was 15.8% and that of grade ≥3b was 5.3%. In the matched case-control study, blood loss was significantly lower in the laparoscopic ISR group. The median postoperative hospital stay was 14.1 days in the laparoscopic ISR group, which was significantly shorter compared with in the open ISR group (18.7 days). Cancer recurrence was detected in one (5%) patient in a single inguinal lymph node. No significant differences between the ISR and ultra-low anterior resection (ULAR) groups were observed in the maximum resting and maximum squeeze pressures; the outcomes for anal function and fecal incontinence were the same for ISR and ULAR. Thus, laparoscopic ISR for lower rectal cancer may provide a benefit in the early postoperative period without increasing morbidity or mortality.

Evaluation of treatment for rectal neuroendocrine tumors sized under 20 mm in comparison with the WHO 2010 guidelines

Rectal neuroendocrine tumor (NET) is a relatively rare lesion of the gastrointestinal tract, but the prospective examination with colonofiberoscopy or endoscopic ultrasound has increased the frequency of its detection. It is often difficult to determine the optimal treatment for NETs sized <20 mm in the clinical setting. Other clinicopathological variables are not considered in the current guidelines and staging systems. Although the effects of lymphovascular invasion are not covered by the World Health Organization (WHO) 2010 guidelines or tumor-node-metastasis (TNM) staging system, this may be promising for the establishment of improved guidelines and staging systems, particularly for early-stage colorectal carcinoids. The aim of the present study was to evaluate rectal NETs sized <20 mm in comparison with the WHO 2010 guidelines. Between January 2005 and December 2013, 40 consecutive patients [26 men and 14 women; median age, 59.3 years (range, 34-81 years)] who underwent endoscopic resection of rectal NETs, and 12 patients undergoing surgical resection of rectal NETs, were enrolled in this retrospective study. The median tumor size was 7.4 mm (range, 3-15 mm). The locations of the NET were the rectosigmoid colon (n=3), the upper rectum (n=13), and the lower rectum (n=25). The NETs were classified by size as 0-5 (n=7), 6-10 (n=29) and 11-15 mm (n=4). The surgical procedures performed included low anterior resection plus esophagectomy (n=1), laparoscopic low anterior resection (n=7) and laparoscopic intersphincteric resection (n=4). Only 1 patient had lymph node metastasis (tumor sized 6-10 mm, with lymphovascular invasion). NET recurrence was not detected in any of the patients. According to the WHO guidelines, the tumors were classified as grade (G)1 (n=8), G2 (n=3) and G1/G2 (n=1). The tumor in the patient with lymph node metastasis was G1. NETs sized <10 mm may be curatively treated by endoscopic resection. However, NETs with either lymphovascular invasion or sized >1 cm carry a risk for metastasis equivalent to that of adenocarcinomas. Therefore, it is mandatory to histologically examine lymphovascular invasion in specimens retrieved via endoscopic resection to determine the necessity for further radical surgery with regional lymph node dissection. The treatment of NETs sized <20 mm as presently defined in the WHO 2010 guidelines requires further evaluation.

The Significant Role of Cyclin D1 in the Synergistic Growth-inhibitory Effect of Combined Therapy of Vandetanib with 5-Fluorouracil for Gastric Cancer

BACKGROUND

5-Fluorouracil (5-FU) has been a mainstay of chemotherapy for gastric cancer. Vandetanib is a tyrosine kinase inhibitor with inhibitory activity against vascular endothelial growth factor receptor and epidermal growth factor receptor (EGFR). We investigated the combination effect of vandetanib with 5-FU on gastric cancer cells.

MATERIALS AND METHODS

Anticancer efficacy was assessed by 3-(4,5-dimethyl-2-tetrazolyl)-2,5-diphenyl-2H tetrazolium bromide assay of five gastric cancer cell lines, MKN1, MKN7, MKN45, MKN74, and TMK1. Signal expression was examined by western blot, and the cell-cycle distribution was assessed by flow cytometry. In vivo anticancer activity of vandetanib with/without 5-FU was tested in MKN74 cells on nude mice.

RESULTS

Vandetanib inhibited the growth of all cell lines. In MKN7 and MKN74 cells, the combination of 5-FU and vandetanib had synergistic effects, but effects were only additional against the other cell lines in vitro. Combination chemotherapy in vivo also significantly inhibited tumor growth compared to single use of each drug. Flow cytometry showed vandetanib increased the proportion in the G₁ phase, and in MKN74, combination therapy increased the early S phase and caused bimodal peaks in the G₁ phase. The level of expression of cyclin D1 was clearly strong in MKN7 and MKN74 in the natural state, and the expression of cyclin D1, E2 promoter binding factor 1 and thymidylate synthase (TYMS) was inhibited by vandetanib, but not in MKN1 cells. The synergistic effect disappeared in MKN7 and MKN74 cells in vitro when cyclin D1 was knocked-down by siRNA.

CONCLUSION

The synergistic effect of vandetanib with 5-FU is related to vandetanib-induced reduction of TYMS via down-regulation of cyclin D1. Hyperexpression of cyclin D1 might be a biomarker of the synergistic effect.

ALDH1A1-overexpressing cells are differentiated cells but not cancer stem or progenitor cells in human hepatocellular carcinoma

Aldehyde dehydrogenase 1A1 (ALDH1A1) is considered to be a cancer stem cell marker in several human malignancies. However, the role of ALDH1A1 in hepatocellular carcinoma (HCC) has not been well elucidated. In this study, we investigated the relationship between ALDH1A1 and clinicopathological findings and examined whether ALDH1A1 deserves to be a cancer stem cell marker in HCC. Sixty HCC samples obtained from surgical resection were collected for immunohistochemical (IHC) staining. Of these 60 samples, 47 samples of HCC tumorous and non-tumorous tissues were evaluated with qRT-PCR. There was no significant difference in the ALDH1A1-mRNA level between tumorous and non-tumorous tissues. Tumorous ALDH1A1-mRNA level had no relationship with the clinicopathological features. Immunoreactivity of ALDH1A1 was classified into two groups based on the percentage of ALDH1A1-overexpressing cells. The ALDH1A1-high group was significantly associated with low serum levels of α-fetoprotein, small tumor diameter, very little lymphovascular invasion, more differentiated pathology and good stage. The ALDH1A1-high group showed more favorable prognosis for recurrence-free survival. In double-staining IHC, ALDH1A1 was not co-expressed with BMI1, EpCAM, CD13, CD24, CD90 and CD133, which reported as cancer stem cell markers in HCC. In conclusion, ALDH1A1-overexpressing cells could appear to be differentiated cells rather than cancer stem cells in HCC.

Transvaginal resection of a rectal leiomyoma: A case report

The present study reports the case of a patient with a rectal submucosal tumor (leiomyoma) that was resected transvaginally. A 51-year-old female presented with a rectal submucosal tumor on the anterior wall of the lower rectum, located within 3 cm of the anal verge. This location would normally require intersphincteric or abdominal perineal resection. However, in order to minimize the invasiveness of the treatment and reduce post-operative morbidity, transvaginal resection and laparoscopic diverting ileostomy were performed instead. With the patient under general anesthesia, the posterior vaginal mucosa was incised vertically. The tumor was then excised en bloc with the overlying rectovaginal septum and rectal submucosal tumor. A primary repair of the defect and a diverting stoma were performed. The procedure did not present any complications, and the patient was discharged on day 10 post-surgery. The diverting stoma was closed 3 months later, and the sphincter function of the patient following surgery was monitored by manometry. The results of the manometric tests indicated that the patient did not suffer from fecal incontinence. In addition, the patient did not experience anal dysfunction or discomfort following the surgical procedure.

Preoperative Chemotherapy Can Change the Surgical Procedure for Hepatectomy in Patients with Liver Metastasis of Colorectal Cancer

AIM

The benefit of preoperative chemotherapy is evaluated in order to clarify the relationship of tumor site with hepatic vessels for hepatectomy. Tumor location in relation to intrahepatic vessels is critical in the decision to operate, but the argument for this concept remains insufficient. Currently, the response rate is evaluated by the decrease in size or number of tumors but not by hepatic resection range.

PATIENTS AND METHODS

We evaluated 32 patients who underwent hepatectomy after chemotherapy for liver metastases from colorectal cancer (CLM). Tumor diameter was defined by contrast computed tomographic imaging before both chemotherapy and surgery. The targeted vessels were those in the main Glisson capsule and hepatic vein and were indicated to change in the resected area by their treatment.

RESULTS

Tumor size decreased, increased or remained unchanged in 62 (68.9%), 27 (30.0%) and one (1.1%) tumor, respectively. Out of the 29 tumors, reduced resection volume was achieved in 12 (37.9%), and the difference in volume was 17.4±4.15 ml. A significant positive correlation was found between tumor shrinkage rate and final distance from the attached vessels (p=0.017), and a shrinkage rate of 63.6±12.4% was necessary for a tumor to be separated from an attached vessel. The final distance was significantly positively correlated with tumor shrinkage speed (p=0.0027), and a shrinkage speed of 0.64±0.12%/day was expected to enable a a tumor to be separated from its attached vessel.

CONCLUSION

Chemotherapy, especially by favorable combination with molecular targeting agents, even for resectable CLM appears to be acceptable and may lead to increased performance of radical surgical resection.

Novel therapy for locally advanced triple-negative breast cancer

To evaluate a novel therapy for triple-negative breast cancer (TNBC), the biological responses to vitamin K3 (VK3) should be considered with the understanding of the features of breast cancer. In human breast cancer cell lines, the effects of VK3 on cell growth inhibition and the cellular signaling pathway were determined by MTT assay and western blotting. In the in vivo study, a subcutaneous tumor model of breast cancer was created, VK3 was injected into the subcutaneous tumors, and tumor size was measured. The IC₅₀ of VK3 for breast cancer cells was calculated to be 11.3–25.1 μM. VK3 induced phosphorylation of whole tyrosine and epidermal growth factor receptor. VK3 mediated phosphorylation of extracellular signal-regulated kinase (ERK) and c-Jun NH2-terminal kinase (JNK) for 30 min. ERK but not JNK phosphorylation was maintained for at least 6 h. In contrast, another antioxidant agent, catalase, showed no effect on either ERK phosphorylation or growth inhibition. On built-up tumors under the skin of mice, local treatment with VK3 was effective in a time- and dose-dependent manner, and the experiments for total tumor volume also showed a dose-dependent effect of VK3. The expression of phosphorylated ERK was clearly detected at 10.9 times the control in tumor tissue, whereas ethanol itself showed no effect. In conclusion, ERK plays a critical role in VK3-induced growth inhibition, and it will be the focus of next steps in the development of molecular therapy for TNBC.

Findings in pancreatic MRI associated with pancreatic fibrosis and HbA1c values

PURPOSE

To evaluate the diagnostic performance of noncontrast-enhanced magnetic resonance imaging (MRI) to grade pancreatic fibrosis and to assess hemoglobin (Hb) A1c values.

MATERIALS AND METHODS

Twenty-nine consecutive patients with pancreatic or biliary malignancy who underwent pancreatectomy were evaluated. Patients were classified into three groups: HbA1c < 5.7 (group 1), 5.7 ≤ HbA1c < 6.5 (group 2), and HbA1c ≥ 6.5 (group 3). MRI of the pancreas was performed using a 1.5T MR system. The pancreas-to-muscle signal intensity ratio (SIR) on in- and opposed-phase T1 -, T2 -, and diffusion-weighted images, as well as the apparent diffusion coefficient were calculated. MRI measurements, degrees of pancreatic fibrosis, and HbA1c values were compared using multiple regression analysis and Kruskal-Wallis test.

RESULTS

The pancreatic fibrosis grade was negatively correlated with the SIR on in-phase T1 -weighted images (r = -0.67, P = 0.0002). The pancreatic fibrosis grade and HbA1c value were negatively correlated with the SIR on opposed-phase T1 -weighted images (r = -0.47, P = 0.019 and r = -0.51, P = 0.0089, respectively). SIRs on in- and opposed-phase T1 -weighted images were significantly lower in group 3 than in groups 1 and 2 (P < 0.05).

CONCLUSION

The pancreas-to-muscle SIRs on in- and opposed-phase T1 -weighted images could be a potential biomarker for pancreatic fibrosis and elevated HbA1c values.

Significance of histopathological evaluation of pancreatic fibrosis to predict postoperative course after pancreatic surgery

BACKGROUND/AIM

Pancreatic stellate cells (PSC) play a critical role in pancreatic fibrosis and the apparent diffusion coefficient (ADC) value based on the diffusion-weighted image (DWI) from magnetic resonance imaging (MRI) may be a predictor of tissue fibrosis. This study aimed to evaluate the pancreas texture from both histopathological and radiological viewpoints and to investigate the effect of pancreas texture on occurrence of postoperative pancreatic fistula (PF).

PATIENTS AND METHODS

We divided 40 patients into soft-pancreas group and hard-pancreas group, according to the histopathological evaluation of pancreatic fibrosis. We compared ADC values and occurrences of PF between the two groups.

RESULTS

Histopathological measurement lengths of interlobular and intralobular fibrosis increased significantly with the progression of fibrosis grade and PSC stage, while PSC stage correlated significantly with fibrosis grade (r=0.868, p<0.001). PF was detected in 14 out of 40 patients, including grade A in 7 patients and grade B/C in 7 patients, but there were no operative deaths. Pancreas texture (soft/hard), determined based on the combination of fibrosis grade and PSC stage, was 16/10 (no PF) and 14/0 (grade A/B/C PF) and the difference in the incidence was significant (p=0.022). Though ADC value was significantly lower in the hard-compared to the soft-pancreas group (1.48±0.42 vs. 1.73±0.27×10(-3) mm(2)/sec; p=0.033), there was no significant difference in ADC value between no PF versus grade A/B/C PF group.

CONCLUSION

Histopathological evaluation of pancreas texture correlated negatively with ADC values and is critical to predict the occurrence of PF.

Retrospective evaluation of the clinical necessity of external biliary drainage after pancreaticoduodenectomy

BACKGROUND/AIMS

To evaluate the efficacy of internal biliary drainage after pancreaticoduodenectomy (PD), postoperative gastrointestinal function and complications of PD were compared in patients with and without the use of an external drainage stent for hepaticojejunostomy (HJ).

METHODOLOGY

Between June 2005 and September 2011, 66 patients who underwent PD, including 40 patients with externally-stented HJ (ES group) and 26 patients with non-stented HJ (NS group), were included in this study, and postoperative bowel movements, oral intake, and complications were assessed.

RESULTS

Time to tolerance of water or solid food were comparable between the two groups, and time to first bowel movement was significantly shorter in the NS group than in the ES group (3.2 +/- 1.6 days versus 4.6 +/- 1.7 days; p = 0.002). There were no differences in the incidence and severity of postoperative complications when comparing the two groups, whereas the incidence of postoperative cholangitis was significantly higher in the ES group (25.0%) than in the NS group (3.8%; p = 0.024).

CONCLUSIONS

External biliary drainage may have a negative impact on biliary complications after PD, especially on the incidence of postoperative cholangitis.

Surgical Indications for Multiple and Synchronous Liver Metastases from Colorectal Cancer

Surgical indications for resection of synchronous metastasis from colorectal cancer (CRC) are still controversial. 57 patients with synchronous and multiple metastatic liver tumors were studied. 1) The three-year survival rate and MST for synchronous metastasis, 55% and 28.4 ± 15.4 months, were clearly poorer than those of the patients with metachronous, 100% and 39.9 ± 10.8 months. 2) Three-year survival rate and MST for a single tumor were similar to those for multiple tumors but were 83% and 36.6 ± 14.0 months in patients with ≤ 2 tumors, significantly better (p = 0.0127) than those in patients with 3 tumors, 65% and 24.0 ± 13.6 months. 3) In the patients with synchronous liver tumors, 3-year survival rate and MST after staged hepatectomy were significantly better, 82% and 34.5 ± 14.9 months (p = 0.0467), than simultaneous hepatectomy, 29% and 23.9 ± 13.6 months. 4) In patients with repeat hepatectomy, the only difference between first vs. repeat hepatectomy was in tumor number detected, 4.4 ± 1.2 vs. 1.2 ± 0.1. The present data show that neoadjuvant chemotherapy might improve patient prognosis, and with 3 tumors, planning of staged hepatectomy is best, even if technically removed.

A case report on efficacy of Abound™ for anti-EGFR antibody-associated skin disorder in metastatic colon cancer

Background

Panitumumab is a full human epidermal growth factor receptor (EGFR) monoclonal antibody, an agent for metastatic colorectal cancer therapy. One of the most general adverse events of anti-EGFR monoclonal antibody therapy is skin disorder. At the present time, although prophylaxis of skin disorder is important for continuation of cancer therapy, there are no effective precautionary treatments.

Case presentation

A 73-year-old male with sigmoid colon cancer and synchronous lung metastasis was treated with panitumumab, an alone anti-EGFR monoclonal antibody as the third-line therapy.

During the nine courses of the therapy, the response was stable disease (SD), but skin disorder gradually appeared obviously (CTCAE version 4.0: Grade 2). After 1 month of administration of Abound™, symptoms of the skin disorder improved (CTCAE version 4.0: Grade 1), thus the antibody therapy could be continued.

Conclusion

We report that Abound™ was apparently effective in the treatment for anti-EGFR antibody-associated skin disorder. In the future, Abound™ could be expected as an agent for skin disorder as one of the side effects of colorectal cancer therapy.

Fibrosis and postoperative fistula of the pancreas: correlation with MR imaging findings--preliminary results

PURPOSE

To assess the potential value of magnetic resonance (MR) imaging in evaluating pancreatic fibrosis and predicting the development of postoperative pancreatic fistula.

MATERIALS AND METHODS

This retrospective study had institutional review board approval, and the requirement for informed consent was waived. MR images obtained in 29 consecutive patients (15 men, 14 women; mean age, 64.9 years; age range, 21-80 years) who underwent pancreatectomy were evaluated. The pancreas-to-muscle signal intensity (SI) ratio on unenhanced T1- and T2-weighted, dynamic contrast material-enhanced, and diffusion-weighted images and the apparent diffusion coefficient (ADC) of the pancreas were measured. MR imaging parameters were correlated with the degrees of pancreatic fibrosis and expression of activated pancreatic stellate cells (PSCs) by using univariate and multivariate regression analyses and receiver operating characteristic curve analysis. The relationships between the development of postoperative pancreatic fistula and the MR imaging measurements were examined by using logistic regression analysis and the Mann-Whitney U test.

RESULTS

Multiple regression analysis showed that pancreas-to-muscle SI ratios on T1-weighted images and ADC values were independently associated with pancreatic fibrosis (r(2) = 0.66, P < .001) and with activated PSC expression (r(2) = 0.67, P < .001). The mean pancreas-to-muscle SI ratio (± standard deviation) on T1-weighted images was higher (P = .0029) for patients with postoperative pancreatic fistula (1.6 ± 0.2) than for those without (1.2 ± 0.2), and the odds ratio for postoperative pancreatic fistula was 21.3 in patients with an SI ratio of 1.41 and higher.

CONCLUSION

The pancreas-to-muscle SI ratio on T1-weighted MR images of the pancreas may be a potential biomarker for assessment of pancreatic fibrosis and prediction of postoperative pancreatic fistula.

Long-term outcomes of treatment of gastric gastrointestinal stromal tumor by laparoscopic surgery: review of the literature and our experience

BACKGROUND/AIMS

Although the feasibility of laparoscopic resection of gastric gastrointestinal stromal tumors (GISTs) has been established, various aspects are debated. This paper describes the problems of minimally invasive resection of gastric GISTs and compares this experience with an extensive literature review.

METHODOLOGY

Between October 2003 and June 2012, 24 consecutive patients undergoing laparoscopic resection of gastric GISTs were enrolled in a prospective study. A comparison with authors' experience with laparoscopic wedge-segmental resection of GISTs was also carried out.

RESULTS

Twenty-four patients, mean age 64.0 +/- 11.2 years, were submitted to laparoscopic wedge-segmental gastric resections. Mean tumor size was 3.1 +/- 1.2 cm, mean operative time was 118.0 +/- 57.3 min, mean blood loss was 21.6 +/- 47.7 mL, and mean hospital stay was 7.1 +/- 1.9 days. There were no major operative complications or mortalities. All lesions had negative resection margins. Postoperative complications were detected in 2 patients. The rate of complication of grade 2 was 8.3%. At a mean follow-up of 23.9 months, all patients were disease-free. Morbidity, mortality, length of stay, and oncologic outcomes were comparable to experience with an extensive literature review. The stomach was divided into 3 areas (U, M, L area). When operation time and blood loss were examined, a significant difference was not indicated. However, both operation time and blood loss of M area tended to be low compared with U area. According to the mitotic index, 21 (87.5%) tumors were evaluated as low risk, 2 (7.3%) tumors as medium risk, and 1 (4.2%) tumor as high risk.

CONCLUSIONS

Laparoscopic resection is safe and effective in treating gastric GISTs. Therefore, a minimally invasive approach should be the preferred surgical treatment in patients with small- and medium-sized gastric GISTs.

Cutaneous vasculitis and glomerulonephritis associated with C4 deficiency

Complete deficiency of the fourth component of complement (C4) is an extremely rare condition. However, it has been reported that partial C4 deficiency can occur in normal subjects, and is associated with several immune diseases. We report a 44-year-old woman who developed slight oedema and punctate purpura on her lower legs after a common cold. She was noted to have persistent microscopic haematuria and proteinuria, and her C4 level was undetectable. On histological examination of a skin biopsy specimen, leucocytoclastic vasculitis was seen, with granular deposition of IgG, IgM, C3 and C1q on the vessel walls in the upper dermis. A renal biopsy showed mild mesangial proliferative glomerulonephritis with slight damage to the capillary loops, and granular deposits of IgM and C4 mainly in the mesangium. The patient was systemically well and needed no medication. The C4 level remained low during the observation period, but neither genotyping nor allotyping analysis identified a C4 deficiency.

Determining timing of hepatectomy for colorectal cancer with distant metastasis according to imaging-based tumor shrinkage ratio

BACKGROUND

The optimal timing of surgical resection of liver metastasis remains controversial, and guidelines regarding the upper limits of operative indications have not yet been defined. Surgical indication for metastasis from colorectal cancer (CLM) based on results of preoperative chemotherapy and RNF8 was investigated.

METHODS

Differences in CLM size on CT were evaluated as shrinkage rate/day by dividing tumor shrinkage rates by the interval in days between CT. Levels of RNF8 of resected colorectal cancer and CLM frozen specimen were detected.

RESULTS

When the cut line for shrinkage rate at 12 weeks was set at 0.35%, disease-free survival was significantly better in patients with a shrinkage rate >0.35% vs. ≤0.35% (p=0.003). RNF8 expression was significantly higher in Tis (p=0.001). In liver metastasis, RNF8 expression level was significantly lower in patients with partial response to FOLFOX than with stable disease, (p=0.017).

CONCLUSIONS

A strategy of FOLFOX administration for 12 weeks to patients with low RNF8 expression and hepatectomy planned after 4 weeks rest may be accepted as the best therapeutic option for treating CLM.

Two rare cases of a solid pseudopapillary neoplasm of the pancreas

A solid pseudopapillary neoplasm (SPN) of the pancreas has distinct histopathological features. A solid pattern of growth with pseudopapillary structures that result from degeneration is observed. On rare occasions, the tumor may vary from being entirely solid to completely cystic. The present study describes two unique cases of SPN. A 25-year-old male presented with a pancreatic tumor showing a predominantly solid pattern with no degenerative change, although the pre-operative cytological specimens that were obtained by endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) revealed pseudopapillary structures. The second case was of an 11-year-old female who presented with a pancreatic tumor with prominent degeneration. Nests and cords of the remaining neoplastic cells were located only at the periphery, with perineural invasion. An immunohistochemical analysis revealed that the tumor cells in the two cases were positive for CD10 and β-catenin and negative for trypsin. An awareness of the broad morphological variability of SPN and an immunohistochemical panel that includes CD10, β-catenin and trypsin are useful for establishing an accurate diagnosis.

Laparoscopic technique and safety experience with barbed suture closure for pelvic cavity after abdominoperineal resection

BACKGROUND

Between April 2005 and December 2012, we performed laparoscopic colorectal resection with regional lymph node dissection on 273 cases of colorectal cancer patients. However, Laparoscopic rectal cancer surgery requires a high degree of skill. Any surgeon who is going to embark on these difficult resections should have at a minimum laparoscopic suturing skills in order to be able to close the peritoneal defect.

METHODS

In laparoscopic surgery for rectal cancer, the intracorporeal suture technique required to close the pelvic cavity is very difficult. Barbed sutures have recently been proposed to facilitate laparoscopic suturing. Two patients with rectal cancer who underwent laparoscopic abdominoperineal resection (APR) with intracorporeal closure of the pelvic cavity from September to October 2012 were enrolled in this study.

RESULTS

We present our initial experience of two consecutive cases of intracorporeal closure of the pelvic cavity by totally laparoscopic APR. After clinical follow-up, the two patients have no complaints and have shown no signs of recurrence.

CONCLUSIONS

We hypothesized that barbed sutures could potentially improve the efficiency of intracorporeal closure of the pelvic cavity after laparoscopic APR. Further, we expect that use of the V-Loc™ will reduce intra-operative stress on the endoscopic surgeon.

Predictive value of orotate phosphoribosyltransferase in colorectal cancer patients receiving 5-FU-based chemotherapy

Pretreatment knowledge of chemosensitivity and side-effects of chemotherapy for colorectal cancer (CRC) patients are likely to ensure the best chemotherapeutic outcome. The aim of this study was to identify additional predictive factors of chemosensitivity to the key CRC treatment drug 5-fluorouracil (5-FU). Surgically obtained specimens from 106 patients treated for CRC were immunohistochemically assessed to investigate the correlation between the protein expression of the 5-FU metabolic enzymes orotate phosphoribosyltransferase (OPRT), thymidylate synthase (TS) and dihydropyrimidine dehydrogenase (DPD), and clinicopathological characteristics as well as the correlation between the protein expression and outcomes of 5-FU-based chemotherapy. A correlation was detected between the high expression of the 5-FU metabolic enzyme OPRT and negative lymph node metastasis (P=0.0496), as well as between DPD and advanced Tumor-Node-Metastasis (TNM) grade cases (IIIA-IVB) and positive lymph node metastases (P=0.0414, respectively). In all 106 patients and in 79 patients undergoing 5-FU-based chemotherapy, survival was improved in those patients with a positive OPRT expression (P=0.0144 and 0.0167, respectively). OPRT expression was higher in the 79 patients with no recurrence (P=0.0179) as well as in patients treated with R0 surgery and 5-FU-based chemotherapy without side-effects (P=0.0126). Disease-free survival (DFS) rate was higher in patients without side-effects, and in patients with a positive OPRT expression without side-effects (P=0.0021 and 0.0031, respectively). Findings of this study demonstrated that OPRT expression positively correlated with fewer side-effects of 5-FU-based chemotherapy and longer patient survival.

Extracellular signal-regulated kinase and Akt activation play a critical role in the process of hepatocyte growth factor-induced epithelial-mesenchymal transition

Epithelial-mesenchymal transition (EMT) has recently been studied to elucidate mechanisms of the liver metastatic process. We investigated EMT in the process of liver metastasis and the effects of chemotherapy on EMT cells as therapeutic strategy for colorectal liver metastasis. We used the CT26 murine colorectal carcinoma cell line to create an in vivo mouse liver metastasis model. Liver tumors were stained immuno-histochemically. Expression of proteins associated with TGF-β/Smad and hepatocyte growth factor (HGF)/c-Met pathways were investigated by western blotting. Cells with c-Met mRNA knockdown by siRNA techniques showed clearly reduced liver metastases compared with regular cells at 21 days. TGF-β and HGF induced EMT expression, but signal transduction was quite different. TGF-β induced ERK, but not Akt phosphory-lation. HGF mediated both ERK and Akt phosphorylation. Akt inhibitor blocked Akt phosphorylation but did not affect TGF-β-induced activation of ERK, Snail and Slug. U-0126 did not reduce Snail activity by TGF-β at a concentration to block ERK phosphorylation. However, Akt inhibitor and U-0126 completely inhibited HGF-induced Slug activation. 5-FU mediated cell death in the EMT process induced by TGF-β more effectively than HGF. ERK/Akt signaling, but not the Smad pathway, may be one of the main processes in HGF-induced EMT, despite the Smad pathway, but not ERK/Akt, being critical for TGF-β-induced EMT. The MAPK/Akt pathway is indispensable in HGF/c-Met signaling. The ERK/Akt pathway particularly may be critical in the HGF-induced EMT process. However, long-term use of chemotherapeutic agents may induce drug resistance and distant metastases through EMT-related signaling pathway activation.

Human gastric cancer organizes neighboring lymphatic vessels via recruitment of bone marrow-derived lymphatic endothelial progenitor cells

BACKGROUND

Lymphatic metastasis is a critical determinant of prognosis in human gastrointestinal cancers. Studies suggest that lymphatic metastasis has been linked to lymphangiogenesis, the growth of lymphatic vessels, while the mechanisms of tumor lymphangiogenesis remain poorly characterized.

METHODS

Human gastric cancer cells, MKN45, were implanted under the gastric submucosa of nude mice receiving green fluorescent protein-positive bone marrow (BM) transplants. In addition, MKN45 cells were subcutaneously injected into the back of each mouse as a model of human tumor xenografts. The tumor tissue was analyzed 3 weeks after implantation.

RESULTS

The mice with MKN45 cells represent recruitment and incorporation of BM-derived lymphatic endothelial progenitor cells (LEPC) into gastric lymphatics. Moreover, in a xenograft model, MKN45 cells induced lymphangiogenesis as well as recruitment of BM-derived LEPC in tumor lymphatics in a xenograft model.

CONCLUSIONS

These findings of this study suggest that human gastric adenocarcinoma induces tumor lymphangiogenesis via recruitment of LEPC from BM.

Therapeutic strategies for synchronous and multiple liver metastases from colorectal cancer

Metastasis in the liver is one of the most critical factors in the prognosis of patients with colorectal cancer. The incidence of synchronous liver metastasis has been found to be approximately 20-25%, but the optimal timing of surgical resection remains controversial. Neoadjuvant chemotherapy has also been found to be beneficial not only for initially unresectable but also resectable synchronous metastases and traditional surgical strategies of hepatic resection with past chemotherapeutic regimens have been used less and less over the past several years. This review will discuss treatments in association with the recently developed chemotherapeutic regimens.

Strategy for synchronous and multiple liver metastasis

BACKGROUND/AIMS

Surgical indications for resection of synchronous metastasis from colorectal cancer (CRC) and the optimal timing of hepatectomy are still controversial and widely debated.

METHODOLOGY

Synchronous and multiple metastatic liver tumors were detected in 57 patients since May 2005. Our treatment policy was to perform hepatectomy if the resection could be done with no limit on size and number of tumors. However, if curative resection could not be done, chemotherapy was begun and timing for the possibility of a radical operation was planned immediately.

RESULTS

In 37 patients whose tumors were located only in the liver, primary tumor resection was performed in 16 patients and after tumor-decreasing by chemotherapy, in 7 patients. In 20 patients in whom chemotherapy was performed first, after controlling the distant metastasis, hepatectomy was performed in 3 patients and staged hepatectomy was performed in 10. Recurrence was detected after hepatectomy in 75.0% of simultaneous resection cases and in 70.0% of staged cases. In the recurrence cases, early detection after tumor resection occurred in 58.3% of the simultaneous and 14.2% of the staged.

CONCLUSIONS

The present data show that neoadjuvant chemotherapy does not increase the risk of postoperative complications or the surgical difficulties of hepatectomy for colorectal metastases.

Therapeutic strategies for synchronous and multiple liver metastases from colorectal cancer

Metastasis in the liver is one of the most critical factors in the prognosis of patients with colorectal cancer. The incidence of synchronous liver metastasis has been found to be approximately 20–25%, but the optimal timing of surgical resection remains controversial. Neoadjuvant chemotherapy has also been found to be beneficial not only for initially unresectable but also resectable synchronous metastases and traditional surgical strategies of hepatic resection with past chemotherapeutic regimens have been used less and less over the past several years. This review will discuss treatments in association with the recently developed chemotherapeutic regimens.

Reconstruction method after pancreaticoduodenectomy. Idea to prevent serious complications

Pancreatic fistula after pancreaticoduodenectomy represents a critical trigger of potentially life-threatening complications and is also associated with markedly prolonged hospitalization. Many arguments have been proposed for the method to anastomosis the pancreatic stump with the gastrointestinal tract, such as invagination vs. duct-to-mucosa, Billroth I (Imanaga) vs. Billroth II (Whipple and/or Child) or pancreaticogastrostomy vs. pancreaticojejunostomy. Although the best method for dealing with the pancreatic stump after pancreaticoduodenectomy remains in question, recent reports described the invagination method to decrease the rate of pancreatic fistula significantly compared to the duct-to-mucosa anastomosis. In Billroth I reconstruction, more frequent anastomotic failure has been reported, and disadvantages of pancreaticogastrostomy have been identified, including an increased incidence of delayed gastric emptying and of pancreatic duct obstruction due to overgrowth by the gastric mucosa. We review recent several safety trials and methods of treating the pancreatic stump after pancreaticoduodenectomy, and demonstrate an operative procedure with its advantage of the novel reconstruction method due to our experiences.

[Treatment of advanced gastric cancer in the elderly]

Because the aging process varies among individuals, elderly people of the same age, especially those over 80 years, do not necessarily have similar organ function. After consideration of lower organ function and concomitant disease, less invasive treatment should be selected for elderly patients. Therefore, it is important to limit preventive lymph node dissection, and when determining the dose of anticancer drugs, major organ function should be taken into consideration.

Growth effect of neutrophil elastase on breast cancer: favorable action of sivelestat and application to anti-HER2 therapy

AIM

To investigate the relation between neutrophil elastase (NE) and proliferation of breast cancer cells and whether the NE inhibitor sivelestat could both contribute and be applied to therapy for anti-epithelial growth factor receptor 2 (HER2)-positive breast cancers.

MATERIALS AND METHODS

The proliferation or inhibition of breast cancer cell line SKBR-3 by each agent was evaluated by methylthiazole tetrazolium (MTT) assay. Signal transduction and expression of signaling molecules were evaluated by Western blot analysis.

RESULTS

The auto tumor progression mechanism initiated by NE through tumor growth factor-α (TGF-α) was present in breast cancer cells, and this mechanism was intensively suppressed by sivelestat. The effect of trastuzumab was suppressed, and trastuzumab-induced HER2 down-regulation was impaired by TGF-α. TGF-α not only promoted cell proliferation as a ligand but also enhanced resistance to trastuzumab by impairing HER2 down-regulation. Furthermore, combined use of trastuzumab and sivelestat suppressed cell proliferation more intensively than either drug alone and did not provoke impairment by TGF-α of HER2-induced down-regulation.

CONCLUSION

Combinatorial use of sivelestat and trastuzumab might be a novel therapeutic strategy for HER2-positive breast cancer.

Docetaxel, nedaplatin, and S-1 (DGS) chemotherapy for advanced esophageal carcinoma: a phase I dose-escalation study

AIM

More effective regimens are urgently needed for treatment of esophageal carcinoma; therefore, we conducted a phase I trial of a combination of docetaxel, nedaplatin, and S-1 (DGS) to determine the optimal dose in patients with advanced esophageal carcinoma.

PATIENTS AND METHODS

We studied 14 patients with previously untreated advanced cervical esophageal carcinoma with T3-4 tumors and/or M1 staging and esophageal carcinoma with cervical lymph node metastasis. The patients received an infusion of docetaxel at different dose levels (levels 1, 2, 3, 4: 25, 30, 35, 40 mg/m(2), respectively) and an infusion of nedaplatin (40 mg/m(2)) on day 8 plus oral administration of S1 (80 mg/m(2)/day) for two consecutive weeks at two-week intervals.

RESULTS

Dose-limiting toxicities (DLTs) included febrile neutropenia and leukopenia. DLTs occurred in 2 out of 5 patients at level 4. The response rate was 78.6 (11/14)%, including a complete response rate of 35.7(5/14)%.

CONCLUSION

The DGS regimen reported here was well tolerated and toxicities were manageable. The maximum tolerated dose was level 4, and the recommended dose was determined to be docetaxel at 35 mg/m(2) with nedaplatin at 40 mg/m(2) plus S1 at 80 mg/m(2). We found that our regimen, administered on an outpatient basis, showed high activity and tolerance. A phase II study has been started.

The roles of surgical oncologists in the new era: minimally invasive surgery for early gastric cancer and adjuvant surgery for metastatic gastric cancer

In the new era of technical development in surgery, operative devices, molecular targeting and chemotherapeutic agents, surgical oncologists have two main roles in the treatment of gastric cancer. One is to provide patients with minimally invasive surgery, including laparoscopy- or robot-assisted surgery in early gastric cancer patients, and the new concept of surgical intervention toward advanced and metastatic disease. Since recently, laparoscopy-assisted distal gastrectomy has become prevalent in Japan as a surgery which is minimally invasive for the patients and provides them with a good quality of life afterwards. However, the provision of advanced surgical techniques, including lymph node dissection and reconstruction, is more important for patient survival. The second role of surgical oncologists is to evaluate the significant values of the aggressive treatment which we term 'adjuvant surgery' for stage IV gastric cancer patients who have successfully responded to initial chemotherapy for curative intent. Stage IV gastric cancer patients are now being informed about the possibility of longer survival with the new chemotherapeutic and surgical strategic approach.

Mucinous cystic neoplasm of the pancreas in a male patient

Mucinous cystic neoplasms (MCNs) make up a morphologic family of similar appearing tumors arising in the ovary and various extraovarian organs such as pancreas, hepatobiliary tract and mesentery. MCNs of the pancreas occur almost exclusively in women. Here, we report a rare case of MCN in a male patient. A 39-year-old man was admitted to our hospital with the chief complaint of back pain. Abdominal computed tomography revealed a multilocular cyctic mass 6.3 cm in diameter in the pancreatic tail. In addition, the outer wall and septae with calcification were demonstrated in the cystic lesion. On magnetic resonance imaging , the cystic fluid had low intensity on T1-weighted imaging and high intensity on T2-weighted imaging. Endoscopic retrograde cholangio-pancreatography (ERCP) showed neither communication between the cystic lesion and the main pancreatic duct nor encasement of the main pancreatic duct. Endoscopic ultrasonography revealed neither solid component nor thickness of the septae in the cystic lesion. Consequently, we performed distal pancreatectomy with splenectomy under the diagnosis of cystic neoplasia of the pancreas. Histopathologically, the cystic lesion showed two distinct component: an inner epithelial layer and an outer densely cellular ovarian-type stromal layer. Based on these findings, the cystic lesion was diagnosed as MCN.

Signal transduction of vitamin K3 for pancreas cancer therapy

We characterized molecular mechanisms of vitamin K3 (VK3)-induced inhibition of proliferation to evaluate VK3 effectiveness in treating advanced pancreatic cancer. A novel endoscopic drug delivery system, ultrasound injection technique, was used to study local effects of VK3. VK3 inhibited pancreas cancer cell growth by rapid phosphorylation of growth factor receptor and cellular signal factors such as extracellular signal-regulated kinase. VK3 also activated apoptosis, and apoptosis inhibitor antagonized the apoptosis pathway without inhibiting cell growth. Thiol antioxidant treatment completely abrogated VK3-induced ERK but not JNK phosphorylation or inhibition of proliferation. Non-thiol antioxidant did not affect ERK phosphorylation or growth inhibitory actions. Arylation was considered the main mechanism of VK3-induced growth inhibition through ERK activation. VK3 may lead to favorable outcomes in the treatment of pancreatic tumors. Detection of ERK phosphorylation in tissue is important to predict VK3 effect. Endoscopic ultrasound-guided fine-needle injection may be beneficial for treating pancreatic cancer with VK3.