Heterogeneity of management practices surrounding operable gallbladder cancer - results of the OMEGA-S international HPB surgical survey

BACKGROUND

Gallbladder cancer (GBC) is an aggressive, uncommon malignancy, with variation in operative approaches adopted across centres and few large-scale studies to guide practice. We aimed to identify the extent of heterogeneity in GBC internationally to better inform the need for future multicentre studies.

METHODS

A 34-question online survey was disseminated to members of the European-African Hepatopancreatobiliary Association (EAHPBA), American Hepatopancreatobiliary Association (AHPBA) and Asia-Pacific Hepatopancreatobiliary Association (A-PHPBA) regarding practices around diagnostic workup, operative approach, utilization of neoadjuvant and adjuvant therapies and surveillance strategies.

RESULTS

Two hundred and three surgeons responded from 51 countries. High liver resection volume units (>50 resections/year) organised HPB multidisciplinary team discussion of GBCs more commonly than those with low volumes (p < 0.0001). Management practices exhibited areas of heterogeneity, particularly around operative extent. Contrary to consensus guidelines, anatomical liver resections were favoured over non-anatomical resections for T3 tumours and above, lymphadenectomy extent was lower than recommended, and a minority of respondents still routinely excised the common bile duct or port sites.

CONCLUSION

Our findings suggest some similarities in the management of GBC internationally, but also specific areas of practice which differed from published guidelines. Transcontinental collaborative studies on GBC are necessary to establish evidence-based practice to minimise variation and optimise outcomes.

Role of tumour location and surgical extent on prognosis in T2 gallbladder cancer: an international multicentre study

BACKGROUND

In gallbladder cancer, stage T2 is subdivided by tumour location into lesions on the peritoneal side (T2a) or hepatic side (T2b). For tumours on the peritoneal side (T2a), it has been suggested that liver resection may be omitted without compromising the prognosis. However, data to validate this argument are lacking. This study aimed to investigate the prognostic value of tumour location in T2 gallbladder cancer, and to clarify the adequate extent of surgical resection.

METHODS

Clinical data from patients who underwent surgery for gallbladder cancer were collected from 14 hospitals in Korea, Japan, Chile and the USA. Survival and risk factor analyses were conducted.

RESULTS

Data from 937 patients were available for evaluation. The overall 5-year disease-free survival rate was 70·6 per cent, 74·5 per cent for those with T2a and 65·5 per cent among those with T2b tumours (P = 0·028). Regarding liver resection, extended cholecystectomy was associated with a better 5-year disease-free survival rate than simple cholecystectomy (73·0 versus 61·5 per cent; P = 0·012). The 5-year disease-free survival rate was marginally better for extended than simple cholecystectomy in both T2a (76·5 versus 66·1 per cent; P = 0·094) and T2b (68·2 versus 56·2 per cent; P = 0·084) disease. Five-year disease-free survival rates were similar for extended cholecystectomies including liver wedge resection versus segment IVb/V segmentectomy (74·1 versus 71·5 per cent; P = 0·720). In multivariable analysis, independent risk factors for recurrence were presence of symptoms (hazard ratio (HR) 1·52; P = 0·002), R1 resection (HR 1·96; P = 0·004) and N1/N2 status (N1: HR 3·40, P < 0·001; N2: HR 9·56, P < 0·001). Among recurrences, 70·8 per cent were metastatic.

CONCLUSION

Tumour location was not an independent prognostic factor in T2 gallbladder cancer. Extended cholecystectomy was marginally superior to simple cholecystectomy. A radical operation should include liver resection and adequate node dissection.

Abstract P2-01-19: Sphingosine-1-phosphate affects tumor-associated macrophages in breast cancer patients

Background: Tumor-associated macrophages (TAMs) are considered to be one of the key players in the tumor microenvironment, which regulates cancer invasion and metastases. TAMs can be divided into two phenotypes with opposite functions. While M1 macrophages are known to exert anti-tumor activity by promoting pro-inflammatory effects and immune responses such as intereukin-6 (IL-6) and tumor necrosis factor-α (TNF-α), M2 macrophages influence an anti-inflammatory response, wound healing, and pro-tumorigenic properties. A bioactive lipid mediator, sphingosine-1-phosphate (S1P) has emerged as a key regulatory molecule in cancer progression. We previously demonstrated that S1P generated by sphingosine kinase 1 (SPHK1), is a crucial mediator of breast cancer-induced angiogenesis and lymphangiogenesis, and promotes its metastasis. In particular, we found that SPHK1 is highly expressed in HER2 negative breast cancer, and the patients who developed lymph node metastasis demonstrated significantly higher levels of S1P (J Surg Res 2016). Although we have previously reported the role of S1P in recruitment of TAMs in vivo (Cancer Res 2018), its relevance in patients is yet to be uncovered. Here, we test our hypothesis that S1P signaling affects TAMs in human patients with breast cancer.

Materials and Methods: The expression level of each enzyme-encoding gene involved in S1P production was evaluated by retrieving RNA sequencing and gene expression quantification data using the Genomics Data Commons (GDC) data portal of the The Cancer Genome Atlas cohort. Gene expression levels were derived using normalization methods provided in the DESeq2 package. We compared the difference in expression levels of tumor associated macrophage related genes, including CD68, CD163, IL-6, andTNF-α between SPHK1-high breast tissue, and SPHK1-low breast tissue in the group of HER2 negative or positive patients. Unpaired t-tests were performed to compare expression differences between SPHK1-high and SPHK1-low breast tissue. All tests were two-sided and P values &lt; 0.05 were considered statistically significant.

Results: CD68, pan-macrophage marker, is significantly increased in SPHK1-high breast cancer tissues both in HER2 negative and positive breast cancer patients (p=&lt;0.001, &lt;0.01). CD163 which is a scavenger receptor that is regarded as highly specific for M2 macrophages is significantly increased in SPHK1-high breast cancer tissues in HER2 negative breast cancer patients, but not in HER2 positive breast cancer patients (p=&lt;0.001, 0.2). IL-6, which characterize M1 phenotype is significantly increased in SPHK1-high breast cancer tissues both in HER2 negative and positive breast cancer patients (p=&lt;0.001, &lt;0.001). TNF-α, which also characterizes M1 phenotype, is significantly increased in SPHK1-high breast cancer tissues in HER2 negative breast cancer patients, but not in HER2 positive breast cancer patients (p=&lt;0.001, 0.05).

Conclusion: Our results suggest that S1P affects TAMs in breast cancer patients, which implicate the important roles of S1P in the complicated immune system related to tumor progression. Our results also indicate that S1P have a large role in HER2 negative breast cancer patients. Further investigations are needed to understand the underlying mechanisms.

Citation Format: Tsuchida J, Nagahashi M, Moro K, Ikarashi M, Koyama Y, Sakata J, Kobayashi T, Kameyama H, Qi Q, Yan L, Takabe K, Wakai T. Sphingosine-1-phosphate affects tumor-associated macrophages in breast cancer patients [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-01-19.

Abstract P1-01-06: Targeting the SphK1/S1P/S1PR1 axis that connects obesity, chronic inflammation, and breast cancer metastasis

Introduction: Obesity with associated inflammation is now recognized as a risk factor for breast cancer and increased incidence of distant metastases. However, the link between obesity and breast cancer progression remains poorly understood. There is growing evidence that sphingosine-1-phosphate (S1P), a pleiotropic bioactive sphingolipid metabolite enriched both in blood and lymphatic fluid is involved in inflammation, obesity, and breast cancer progression. Our hypothesis is that obesity increases levels of S1P in both tumor and its microenvironment, which play a role in obesity-induced inflammation and breast cancer metastasis. The aim of this study is to test this hypothesis in in vitro and in vivo as well as patient settings.

Methods: Levels of sphingolipids including S1P in serum from breast cancer patients were quantified. Orthotopically-implanted E0771 syngeneic breast cancer and MMTV-PyMT transgenic breast cancer mouse models were used. Mice were fed with normal or high-fat diet (HFD). FTY720 was administered orally (1 mg/kg/day). To examine pre-metastatic niche formation, a mouse model utilizing tail vein injection of E0771 cells was used. In this model, mice were treated with conditioned media from E0771 breast cancer cells overexpressing SphK1 (K1-CM) or that from E0771 cells cultured with the vector control (CT-CM), prior to tail vein injections of naive E0771 cells. S1P levels were determined by electrospray ionization-tandem mass spectrometry.

Results: We found that obesity significantly increased S1P levels in serum from breast cancer patients. In animal breast cancer models, HFD upregulated expression of sphingosine kinase 1 (SphK1), the enzyme that produces S1P, and its receptor S1PR1 in syngeneic and spontaneous breast tumors. HFD also significantly increased S1P in breast tumors and in the tumor interstitial fluid, which is a component of the tumor microenvironment and bathes cancer cells in the tumor. Targeting the SphK1/S1P/S1PR1 axis with FTY720/fingolimod attenuated obesity-induced key pro-inflammatory cytokines, macrophage infiltration, and tumor progression. In addition, S1P produced by tumor SphK1 primed lung pre-metastatic niches, increased macrophage recruitment into the lung, and induced IL-6 and signaling pathways important for lung metastatic colonization. FTY720 suppressed HFD-induced lung IL-6 and macrophage infiltration as well as S1P-mediated signaling pathways and dramatically reduced formation of metastatic foci. In tumor bearing mice, FTY720 also suppressed obesity-related inflammation, S1P signaling, pulmonary metastasis, and prolonged survival.

Conclusion: Our results highlight a critical role for circulating S1P produced by tumor and the SphK1/S1P/S1PR1 axis in obesity-related inflammation, metastatic niche formation and breast cancer metastasis and suggest that targeting the SphK1/S1P/S1PR1 axis would be a useful therapeutic for obesity promoted metastatic breast cancer.

Citation Format: Nagahashi M, Yamada A, Aoyagi T, Huang W-C, Terracina KP, Hait N, Allegood JC, Tsuchida J, Nakajima M, Katsuta E, Milstien S, Wakai T, Spiegel S, Takabe K. Targeting the SphK1/S1P/S1PR1 axis that connects obesity, chronic inflammation, and breast cancer metastasis [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-01-06.

Abstract P1-01-21: The levels of sphingosine-1-phosphate and its related gene expressions in breast cancer patients

Background: The bioactive lipid mediator sphingosine-1-phosphate (S1P) has emerged as a key regulatory molecule in cancer progression. We previously demonstrated that S1P is a crucial mediator of breast cancer-induced angiogenesis and lymphangiogenesis, and promote metastasis. Although increasing number of in vitro and in vivo experiments have revealed the importance of S1P in cancer progression, the data on the roles of S1P in human patients are very limited. The aim of this study is to reveal the clinical relevance of S1P in the interaction between cancer and the tumor microenvironment by examining the levels of the sphingolipids in patient breast cancer tissue samples.

Material and Method: Breast cancer tissue, peri-tumor tissue, and normal breast tissue were collected from 20 breast cancer patients immediately after surgery that were conducted from November 2015 to February 2016 at Niigata University Medical and Dental Hospital. Sphingolipids were quantified by liquid chromatography–electrospray ionization tandem mass spectrometry. The expression level of each enzyme-encoding gene involved in S1P production was evaluated by retrieving RNA sequencing and gene expression quantification data from breast cancer tissues (n = 112) and paired normal breast tissues (n = 112) using the Genomics Data Commons (GDC) data portal of the The Cancer Genome Atlas (TCGA) cohort. Gene expression levels were derived using normalization methods provided in the DESeq2 package.

Result: The levels of the sphingolipids sphingosine (Sph), dihydro-sphingosine (DHSph), S1P, and dihydro-S1P (DHS1P) were successfully determined in breast cancer, peri-tumor, and normal breast tissues from all of the 20 patients. As expected, a one-way ANOVA revealed that S1P levels were significantly different depending on the location (F(2,57) = 7.029, P = 0.002). The Tukey post hoc test revealed that S1P levels in tumors were significantly higher than those in normal breast tissue and peri-tumor tissue (P &lt; 0.05). Similarly, Sph and DHSph levels in tumors were significantly higher than in normal breast tissue and peri-tumor tissue. Both SPHK1 and SPHK2 gene expression levels in breast cancer tissue were higher than those in normal breast tissue. Interestingly, expression of some of the S1P-related genes; S1PR3, ABCC1, SGPL1, and ORMDL2, were significantly increased in the breast cancer tissue compared to normal breast tissue. On the other hand, there was significantly decreased expression of the S1P-related genes S1PR1, S1PR2, ABCG2, SPNS2, SGPP1 and ORMDL3, in breast cancer tissue compared to normal breast tissue.

Conclusion: We demonstrated that the major source of S1P is the tumor tissue, and not the peri-tumor tissue despite the fact that angiogenesis and lymphangiogenesis are occurring more in the peri-tumor area, which implicate that S1P may have further role inside the tumor. Our results indicated the complexity of S1P signaling in human cancer than expected based on the results in vivo experiments.

Citation Format: Tsuchida J, Nagahashi M, Nakajima M, Takabe K, Wakai T. The levels of sphingosine-1-phosphate and its related gene expressions in breast cancer patients [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-01-21.

103 The Tunica Albuginea Increases in Thickness and Density Correlatively with the Age of the Patient in Human Ovaries

A decline in fertility occurs with age. Because the extracellular matrix has a vital role in maintaining the integrity and determining the tissue function of numerous organs, the reasons for this fertility reduction may be associated with changes occurring in the ovarian matrix. To demonstrate this hypothesis, by using Picrosirius Red (PSR), a connective tissue dye specific for fibres of collagen I and III, we examined the ovarian tunica albuginea (TA), a part of the cortex composed by dense connective tissue that protects the ovaries and whose rupture is critical for the occurrence of ovulation events. According to an approval from the Ethics Committee of Okayama University (approval number 1818), ovaries were obtained from patients with gender identity disorder at the Okayama University Hospital. Sliced ovaries were fixed in 4% paraformaldehyde and included in paraffin. Sections of 5 μm thickness were stained with PSR. For each individual, 2 non-overlapping brightfield images were taken of each section with a fluorescence microscope and the attached viewer software (Keyence BZ-X710, Keyence Corp., Osaka, Japan). ImageJ (National Institutes of Health, Bethesda, MD, USA) was used to quantify the distance of the dense connective tissue by selecting 5 random points manually per image and, to quantify the density of the tissue; we detected PSR staining above a determined threshold kept constant for all the images analysed. Statistical analyses of data from 3 replicates per individual were performed by Pearson’s correlation, and a P-value < 0.05 was considered significant. We examined samples from 18 individuals from 21 to 46 years old (mean age ± SD: 30.1 ± 7.5 years). When we observed the PSR histological sections, we could not detect any correlation between dosage and length of the androgenic treatment received by the patients and the thickness and density of the TA (P = 0.76 and P = 0.14, respectively). However, when we contrasted the age of the donor with the previous parameters, we detected a significant positive correlation (r = 0.52, P < 0.05) between the thickness of the TA and the age of the subject, indicating that this layer becomes thicker with increasing age. Furthermore, when we assessed its density, the results indicated a significant positive correlation (r = 0.55, P < 0.05) between age and TA density, meaning that this layer also becomes more compact in older individuals. The thickness of the TA seems to increase due to fibrotic growth underneath this layer, which causes an increase of the total thickness of the dense connective tissue. These areas of fibrosis have no follicles and usually present a clear limit with the rest of the cortical tissue area. In conclusion, we demonstrated that the ovarian cortical area comprising dense connective tissue grew thicker with increasing age without any contribution of the dosage or length of the androgenic treatment. The implications of these findings regarding ovulation, follicular growth, and the potential effects of related hormones such as LH and FSH on the ovaries must be investigated further.

167 DEVELOPMENTAL COMPETENCE OF PORCINE OOCYTES DERIVED FROM SMALL- OR MEDIUM-SIZED FOLLICLES AND DENUDED OF CUMULUS CELLS BEFORE AND DURING IN VITRO MATURATION

This experiment was undertaken to assess the meiotic and developmental competences of oocytes derived from different sized follicles and denuded of cumulus cells 0, 20, and 44 h after the start of culture for in vitro maturation (IVM). Groups of 60 oocyte-cumulus complexes from small- (SF; <3 mm) and medium-sized follicles (MF; 3–6 mm) were cultured for IVM in porcine oocyte medium with 50 μM β-mercaptoethanol supplemented with 1 mM dibutyryl-cyclic adenosine monophosphate, 10 IU mL−1 of eCG, and 10 IU mL−1 of hCG for 20 h at 39°C and 5% CO2 in air. Then, after washing, they continued culture in fresh β-mercaptoethanol without dibutyryl-cyclic adenosine monophosphate and gonadotropins under the same conditions for another 24 h. At 0, 20, and 44 h of IVM, cumulus cells were removed with 0.1% (wt/vol) hyaluronidase and the denuded oocytes continued IVM culture following the protocol. Mature oocytes with the first polar body were selected, parthenogenetically activated with a single electrical pulse (DC: 1.2 kV/cm, 30 µs), incubated with 4% (wt/vol) BSA and 5 μM cytochalasin B for 4 h, and cultured in porcine zygote medium for 5 days. Cleavage and blastocyst formation rates were observed on Day 2 and 5, respectively. Blastocysts were stained with 4’,6-diamidino-2-phenylindole for cell count assessment. The experiment was replicated 5 times and analysed with a 1- or 2-way ANOVA. If P < 0.05 in ANOVA, a Tukey multiple comparisons test was performed. Regardless of the time of cumulus cell removal, oocytes from MF had significantly higher in rates of maturation, cleavage, and blastocyst rates, as compared with those from SF, whereas there were no significant differences in the cell number of blastocysts between SF and MF (32 v. 34 cells, respectively). When oocytes were denuded before IVM culture, rates of oocyte maturation (37.6% in SF and 50.8% in MF), and blastocyst formation (2.7% in SF and 27.3% in MF) were significantly lower than controls (51.2% in SF and 76% in MF; 25.8% in SF and 48.5% in MF, respectively). When oocytes were denuded 20 h after the start of IVM, oocyte maturation rates were significantly increased (64.1% in SF and 82.5% in MF) as compared with controls, whereas no significant differences were observed in cleavage and blastocyst formation rates in comparison with controls. These results conclude that removing cumulus cells from oocyte-cumulus complexes 20 h after the start of IVM improves the meiotic competence of oocytes derived from both SF and MF, without any reduction of developmental competence of the oocytes following parthenogenetical activation.

Study of Immune Tolerance Cases in Adult Living Donor Liver Transplantation

BACKGROUND

Complete immune tolerance is the chief goal in organ transplantation. This study aimed to evaluate patients who successfully withdrew from immunosuppressive (IS) agents after living donor liver transplantation (LDLT).

MATERIALS AND METHODS

A retrospective review of all adult LDLT from July 1999 to March 2012 was conducted. In patients who acquired immune tolerance after LDLT, their background and the course of surgical procedures were evaluated.

RESULTS

Of a total of 101 adult LDLT patients, 8 patients were completely free of IS agents. Six of these patients (75%) were female, and the median age at the time of transplantation was 56 years (range, 31-66 years). The primary disease causing liver failure was type C liver cirrhosis (50%), fulminant hepatitis (25%), type B liver cirrhosis (12%), and alcoholic liver cirrhosis (12%). The median Child-Pugh score and MELD score were 13 points (range, 8-15 points) and 19 points (range, 10-18 points), respectively. The living related donor was the recipient's child (75%), sibling (12%), or parent (12%). ABO compatibility was identical in 62%, compatible in 25%, and incompatible in 12%.

CONCLUSIONS

In this study, we evaluated the adult patients who successfully withdrew from IS agents after LDLT. In most cases, it took more than 5 years to reduce IS agents. Because monitoring of the serum transaminase level is not adequate to detect chronic liver fibrosis in immune tolerance cases, further study is required to find appropriate protocols for reducing IS agent use after LDLT.

Successful Endoscopic Management of Acute Necrotic Pancreatitis and Walled Off Necrosis After Auxiliary Partial Orthotopic Living-Donor Liver Transplantation: A Case Report

Endoscopic management of acute necrotic pancreatitis and walled off necrosis is less invasive than surgical treatment and has become the 1st choice for treating pancreatic necrosis and abscess. We treated a case of acute necrotic pancreatitis and walled off necrosis after auxiliary partial orthotopic living-donor liver transplantation (APOLT). A 24-year-old woman was admitted to our university hospital for removal of the internal biliary stent, which had already been placed endoscopically for the treatment of biliary stricture after APOLT. She had been treated for acute liver failure by APOLT 10 years before. After we removed the internal stent with the use of an endoscopic retrograde approach, she presented with severe abdominal pain and a high fever. Her diagnosis was severe acute pancreatitis after endoscopic retrograde cholangiography (ERC). Her symptoms worsened, and she had multiple organ failure. She was transferred to the intensive care unit (ICU). Immunosuppression was discontinued because infection treatment was necessary and the native liver had already recovered sufficiently. After she had been treated for 19 days in the ICU, she recovered from her multiple organ failure. However, abdominal computerized tomography demonstrated the formation of pancreatic walled off necrosis and an abscess on the 20th day after ERC. We performed endoscopic ultrasonography-guided abscess drainage and repeated endoscopic necrosectomy. The walled off necrosis diminished gradually in size, and the symptoms disappeared. The patient was discharged on the 87th day after ERC. This is the 1st report of a case of acute necrotic pancreatitis and walled off necrosis that was successfully treated by endoscopic management after APOLT.

Six-Year Graft Survival After Partial Pancreas Heterotopic Auto-Transplantation: A Case Report

BACKGROUND

Long-term graft survival of partial pancreas auto-transplantation after total pancreatectomy has not been clarified. The clinical implications of repeat completion pancreatectomy for locally recurrent pancreatic carcinoma in the remnant pancreas after initial pancreatectomy also have not been clarified.

METHODS

We have previously reported a 61-year-old woman presenting with re-sectable carcinoma of the remnant pancreas at 3 years after undergoing a pylorus-preserving pancreaticoduodenectomy for invasive ductal carcinoma of the pancreas head. We also performed distal pancreas auto-transplantation with the use of a part of the resected pancreas to preserve endocrine function.

RESULTS

The patient was discharged at 20 days after surgery without any complications. She had been followed regularly in our outpatient clinic. She had been treated with S-1 as adjuvant chemotherapy; 72 months after the completion total pancreatectomy with distal partial pancreas auto-transplantation, the patient was alive without any evidence of the pancreatic carcinoma recurrence. The pancreas graft was still functioning with a blood glucose level of 112 mg/dL, HbA1C of 6.7%, and serum C-peptide of 1.2 ng/mL; and urinary C-peptide was 11.6 μg/d.

CONCLUSIONS

Our patient demonstrated that repeated pancreatectomies can provide a chance for survival after a locally recurrent pancreatic carcinoma if the disease is limited to the remnant pancreas. An additional partial pancreas auto-transplantation was successfully performed to preserve endocrine function. However, the indications for pancreas auto-transplantation should be decided carefully in the context of pancreatic carcinoma recurrence.

Abstract P2-05-11: Sphingosine-1-phosphate signaling promotes metastatic niches and lung metastasis in obesity-related breast cancer

INTRODUCTION: The link between obesity and elevated breast cancer mortality is well known, however, the underlying mechanisms are poorly understood. Sphingosine-1-phosphate (S1P) is a pleiotropic bioactive lipid mediator produced by sphingosine kinases (SphKs) that plays critical roles in inflammation and cancer progression. Previously, we found that obesity increases levels of S1P not only in breast tumors, but also in the lung. "Metastatic niches" are specialized microenvironments in distant organs primed by factors from cancer cells. We hypothesized that S1P secreted from the primary tumor could promote formation of a "metastatic niche" in the lung, which assists circulating cancer cells to form metastatic lesions. Further, HFD-induced obesity increases S1P secretion from the primary tumor, which could promote the formation of "metastatic niches" in the lung and lung metastasis. The aim of this study is to test these hypotheses.

METHODS: A mouse model utilizing tail vein injection of E0771 syngeneic breast cancer cells was used. Prior to tail vein injections of naive E0771 cells, mice were treated with conditioned media from E0771 breast cancer cells overexpressing SphK1 (K1-CM) or that from E0771 cells cultured with the vector control (CT-CM). Histological analysis, RT-qPCR, and western blot were used.

RESULTS: The lungs after K1-CM treatment demonstrated much more infiltration of macrophages with greater IL-6 secretion than lungs from CT-CM mice in areas without metastasis. Furthermore, SphK1, S1P receptor 1 and IL-6 expression were all significantly higher in the lungs of mice treated with K1-CM than with CT-CM, suggesting that S1P secreted from the primary tumor promotes formation of a metastatic niche in the lung. Next, mice were fed with HFD or ND for 12 weeks before treatment with SphK1-CM, and lungs were examined 7 days after intravenous injection of E0771 cells. Histological analysis demonstrated that there were significantly more lung metastases in mice on HFD than in mice on ND. Importantly, treatment with FTY720, a functional antagonist of S1P receptor 1, significantly reduced the lung metastases in HFD fed animals. Immunofluorescent staining revealed higher expression of IL-6 and greater number of F4/80 positive macrophages in mice fed with HFD compared with mice fed with ND, whereas FTY720 dramatically suppressed both IL-6 and macrophage infiltration in the lung of HFD-fed mice. HFD-induced obesity also increased pERK, pAKT, pStat3, and pp65 in the lung, and FTY720 suppressed these signaling pathways.

CONCLUSION: Our results suggest that S1P plays a role in the formation of "metastatic niches" in the lung and lung metastasis of breast cancer, and obesity promotes this process. S1P will be a promising target for treatment of breast cancer metastasis, especially in condition with obesity. This work was supported by the Japan Society for the Promotion of Science (JSPS) Grant-in-Aid for Scientific Research Grant Number 15H05676 and 15K15471 for M.N and 15H04927 for W.T. M.N. is supported by the Uehara Memorial Foundation, Nakayama Cancer Research Institute, and Tsukada Medical Foundation. K.T. is supported by NIH/NCI grant R01CA160688 and Susan G. Komen Investigator Initiated Research Grant IIR12222224.

Citation Format: Nagahashi M, Tsuchida J, Moro K, Tatsuda K, Koyama Y, Takabe K, Wakai T. Sphingosine-1-phosphate signaling promotes metastatic niches and lung metastasis in obesity-related breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-05-11.

206 EFFECT OF ADDITION OF FOLLICULAR FLUID OR GROWTH DIFFERENTIATION FACTOR-9 ON IN VITRO MATURATION OF PORCINE OOCYTES DENUDED 20h AFTER THE START OF IN VITRO MATURATION

The interruption of communication between oocyte and cumulus cells (CC) can trigger meiotic resumption and exogenous additives, such as follicular fluid (FF) and growth differentiation factor-9 (GDF9), can improve oocyte quality and the developmental competence. This study was undertaken to examine if the absence and presence of FF from medium follicles (MF; 3–6 mm in diameter) or recombinant human GDF9 (Biovision, Milpitas, CA, USA) during the first or/and second half of in vitro maturation (IVM) had any effects on IVM of oocytes from small follicles (SF; 0.5–2 mm in diameter) or MF when the oocytes were denuded at 20 h after the start of IVM. Cumulus-oocyte complexes (COC) were aspirated from SF or MF of slaughtered prepubertal gilt ovaries. Groups of ~30 COC were cultured in a 300-μL drop of porcine oocyte medium containing 50 µM β-mercaptoethanol (mPOM) with or without 10% (v/v) FF and/or 100 ng mL–1 GDF9 at 39°C and 5% CO2 in air. During the first 20 h after the start of IVM, the medium was supplemented with 1 mM dibutyryl c-AMP, 10 IU mL–1 eCG and 10 IU mL–1 hCG. After the first period of IVM, the CC surrounding the oocytes were removed and the denuded oocytes continued culture for IVM with or without FF or/and GDF9 in the absence of dibutyryl c-AMP and gonadotropins in the same medium for another 24 h. At the end of IVM, meiotic progression of the oocytes was examined by DAPI staining. Statistical analyses from at least 4 replicates data were performed by a 2-way ANOVA and a Tukey’s multiple comparisons test. Removal of CC 20 h after the start of IVM significantly improved the incidence of mature oocytes derived from SF (59.2–64.1% v. 41.6–43.1% in controls, P < 0.05) but not from MF (73.1–78.5% v. 70.6–71.8% in controls), whereas regardless of supplementation with FF or GDF9, the maturation rates were always significantly higher in the denuded oocytes from MF (72.4–83.6%) than SF (57.8–66.2%; P < 0.05). Despite of the origin of COC (SF or MF), maturation rates of oocytes denuded 20 h after the start of IVM were not affected by supplementation with FF or GDF9 during the first and/or second half of IVM (P > 0.05). In summary, CC removal from COC 20 h after the start of IVM promotes nuclear maturation of oocytes from SF. Exogenous additives such as GDF9 and follicular fluid from MF do not seem to affect the promotion of nuclear maturation in our experimental conditions.

204 INADEQUACY OF VASCULAR ENDOTHELIAL GROWTH FACTOR IN CULTURE MEDIUM REDUCES THE VIABILITY OF CUMULUS CELLS AND PREVENTS IN VITRO MATURATION OF PORCINE OOCYTES

Recently, vascular endothelial growth factor (VEGF) has been regarded as an important factor associated with not only follicle development but also meiotic competence of oocytes. However, the mechanism of how VEGF works is poorly understood. In this study, we investigated in vitro maturation (IVM) of oocytes from different sizes in the absence or presence of a VEGF receptor inhibitor, Axitinib. Cumulus-oocyte complexes (COC) were obtained from small follicles (SF; l < 3 mm in diameter) and medium follicles (MF; 3–6 mm in diameter). Each group of 30–40 COC with at least 3 layers of clear and compact cumulus cells (CC) was cultured in 500 μL of modified porcine oocyte medium (POM-β-mercaptoethanol) supplemented with 10 IU mL–1 eCG, 10 IU mL–1 hCG and 1mM dibutyryl-cyclic-adenosine monophosphate (dbc-AMP) for the first 20 h and then without those supplements for another 24 h at 39°C, 5% CO2 in air. During the first 20 h of IVM, culture medium was also supplemented with or without 1.25 nM Axitinib. At 20 h and 44 h after the start of IVM, the oocytes were denuded and stained with 4′6-diamidino-2-phenylindole (DAPI) to observe the nuclear stages. At 20 h after the start of IVM, some COC were also stained with PI and SYBR Green I to evaluate the ratio of live/dead cumulus cells. Statistical analyses of data from 5 replications were analysed by ANOVA and Tukey’s multiple comparison test. As compared with controls at 20 h after the start of IVM, the number of dead cumulus cells increased significantly in the groups treated with Axitinib, regardless of COC derived from MF and SF (16.8 v. 43.1% in MF and 25.3 v. 57.7% in SF, P < 0.01, respectively). At that time, a majority of oocytes from MF and SF remained at the germinal vesicle (GV) stage in controls (89.8 and 84.6%, respectively), but the percentage significantly reduced in the presence of Axitinib (57.9 and 48.9% of oocytes from MF and SF, respectively) and proceeded around the metaphase-I stage (37.5 and 44.8% of oocytes from MF and SF, respectively). At 44 h after the start of IVM, lower maturation rates were observed in oocytes treated with Axitinib than controls (35.0 v. 81.2% in MF; 20.1 v. 49.0% in SF; P < 0.01). In conclusions, VEGF plays an important role in maitaining the viability of cumulus cells. The presence of VEGFR inhibitor caused the oocytes to develop uncontrollably, even in the presence of dbc-AMP. Moreover, the deficiency of VEGF prevented oocytes fully competent to resume meiosis and arrest to metaphase II.

Three types of simultaneous pancreas and kidney transplantation

PURPOSE

The purposes of this study were to study and compare clinical and functional outcomes after simultaneous deceased donor pancreas and kidney transplantation (SPK DD), simultaneous deceased donor pancreas and living donor kidney transplantation (SPK DL), and simultaneous living donor pancreas and kidney transplantation (SPK LL).

METHODS

From January 1, 1996 to September 1, 2005, 8918 primary, simultaneous pancreas and kidney transplantation (SPK) procedures were reported to the International Pancreas Transplant Registry. Of these, 8764 (98.3%) were SPK DD, 115 (1.3%) were SPK DL, and 39 (0.4%) were SPK LL. We compared these 3 groups with regard to several endpoints including patient and pancreas and kidney graft survival rates.

RESULTS

The 1-year and 3-year patient survival rates for SPK DD were 95% and 90%, 97% and 95% for SPK DL, and 100% and 100% for SPK LL recipients, respectively (P ≥ .07). The 1-year and 3-year pancreas graft survival rates for SPK DD were 84% and 77%, 83% and 71% for SPK DL, and 90% and 84% for SPK LL recipients, respectively (P ≥ .16). The 1-year and 3-year kidney graft survival rates for SPK DD were 92% and 84%, 94% and 86% for SPK DL, and 100% and 89% for SPK LL recipients, respectively (P ≥ .37).

CONCLUSIONS

Patient survival rates and graft survival rates for pancreas and kidney were similar among the 3 groups evaluated in this study.

Laparoscope-assisted Hassab's operation for esophagogastric varices after living donor liver transplantation: a case report

This is the first successful report of a laparoscope-assisted Hassab's operation for esophagogastric varices after living donor liver transplantation (LDLT). A 35-year-old man underwent LDLT using a right lobe graft as an aid for primary sclerosing cholangitis (PSC) in 2005. Follow-up endoscopic and computed tomography (CT) examinations showed esophagogastric varices with splenomegaly in 2009 that increased (esophageal varices [EV]: locus superior [Ls], moderator enlarged, beady varices [F2], medium in number and intermediate between localized and circumferential red color signs [RC2]; gastric varices [GV]: extension from the cardiac orifice to the fornix [Lg-cf], moderator enlarged, beady varices [F2], absent red color signs [RC0]). A portal venous flow to the esophagogastric varices through a large left gastric vein was also confirmed. Preoperative Child-Pugh was grade B and score was 9. Because these esophagogastric varices had a high risk of variceal bleeding, we proceeded with a laparoscope-assisted Hassab's operation. Operative time was 464 minutes. Blood loss was 1660 mL. A graft liver biopsy was also performed and recurrence of PSC was confirmed histologically. It was suggested that portal hypertension and esophagogastric varices were caused by recurrence of PSC. Postoperative complications were massive ascites and enteritis. Both of them were treated successfully. This patient was discharged on postoperative day 43. Follow-up endoscopic study showed improvement in the esophagogastric varices (esophageal varices [EV]: locus superior [Ls], no varicose appearance [F0], absent red color signs [RC0], gastric varices [GV]: adjacent to the cardiac orifice [Lg-c], no varicose appearance [F0], absent red color signs [RC0]) at 6 months after the operation. We also confirmed the improvement of esophagogastric varices by serial examinations of CT.

Development and external validation of a nomogram for overall survival after curative resection in serosa-negative, locally advanced gastric cancer

BACKGROUND

Few nomograms can predict overall survival (OS) after curative resection of advanced gastric cancer (AGC), and these nomograms were developed using data from only a few large centers over a long time period. The aim of this study was to develop and externally validate an elaborative nomogram that predicts 5-year OS after curative resection for serosa-negative, locally AGC using a large amount of data from multiple centers in Japan over a short time period (2001-2003).

PATIENTS AND METHODS

Of 39 859 patients who underwent surgery for gastric cancer between 2001 and 2003 at multiple centers in Japan, we retrospectively analyzed 5196 patients with serosa-negative AGC who underwent Resection A according to the 13th Japanese Classification of Gastric Carcinoma. The data of 3085 patients who underwent surgery from 2001 to 2002 were used as a training set for the construction of a nomogram and Web software. The data of 2111 patients who underwent surgery in 2003 were used as an external validation set.

RESULTS

Age at operation, gender, tumor size and location, macroscopic type, histological type, depth of invasion, number of positive and examined lymph nodes, and lymphovascular invasion, but not the extent of lymphadenectomy, were associated with OS. Discrimination of the developed nomogram was superior to that of the TNM classification (concordance indices of 0.68 versus 0.61; P < 0.001). Moreover, calibration was accurate.

CONCLUSIONS

We have developed and externally validated an elaborative nomogram that predicts the 5-year OS of postoperative serosa-negative AGC. This nomogram would be helpful in the assessment of individual risks and in the consideration of additional therapy in clinical practice, and we have created freely available Web software to more easily and quickly predict OS and to draw a survival curve for these purposes.

238 CAFFEINE PREVENTS A LOSS OF CALCIUM OSCILLATORY RESPONSE ASSOCIATED WITH POSTOVULATORY AGING OF MOUSE OOCYTES

Numerous studies have demonstrated that postovulatory aging of oocytes prior to fertilization has detrimental effects on oocyte quality and developmental competence. Oocyte aging is accompanied by abnormal oocyte activation and subsequent development, suggesting a disruption of Ca2+ oscillations after fertilization. The inositol 1,4,5-trisphosphate receptor type 1 (IP3R1) in mammals is responsible for the majority of Ca2+ release during fertilization (Miyazaki S et al. 1993 Dev. Biol.). Previously, we reported that phosphorylation of IP3R1 at an MPM-2 epitope may play an important role in facilitating the induction of Ca2+ oscillations at the MII stage (Lee B et al. 2006 Development), indicating that IP3R1 phosphorylation may be a good indicator of the health of the oocyte. However, few studies have investigated the alteration of the Ca2+ signaling and IP3R1 function associated with oocyte aging. On the other hand, a previous report showed that caffeine increased MPF activity and suppressed fragmentation after parthenogenetic activation of aged oocytes (Kikuchi K et al. 2000 Biol. Reprod.). Therefore, the purpose of the present study was to examine whether and how Ca2+ oscillatory activity changes during oocyte aging and to test if caffeine prevents the negative effects of oocyte aging. MII mouse oocytes were collected 14 h after hCG injection and cultured in vitro for 8, 24 or 48 h with or without caffeine (5 or 10 mm). Oocyte quality was assessed by the occurrence of spontaneous fragmentation, monitoring of Ca2+ oscillations after exposure to 10 mm strontium chloride, Western blot analysis of IP3R1 phosphorylation and immunostaining of IP3R1. In oocytes in vitro aged for 8 h, the duration of the first Ca2+ rise was significantly decreased compared with fresh MII oocytes, although this reduction was not observed in MII oocytes treated with 5 mm caffeine. The phosphorylation of IP3R1 at the MPM-2 epitope was slightly decreased during oocyte aging in both caffeine and noncaffeine treatment. Importantly, whereas IP3R1 in MII oocytes treated for 8 h with 5 mm caffeine displayed the typical cortical cluster organization, IP3R1 in aged oocytes without caffeine became dispersed in the cytoplasm. In addition, caffeine significantly suppressed the spontaneous fragmentation that is normally observed by 48 h of in vitro culture. These results suggest that the Ca2+ oscillatory activity is compromised during oocyte aging and caffeine prevents the loss of integrity of Ca2+ signaling possibly by keeping the cortical distribution of IP3R1.

Long-term outcomes after hepatectomy for recurrences after prior local ablation for hepatocellular carcinoma

AIMS

Intrahepatic recurrence is the most common manifestation of failure after local ablation therapy for hepatocellular carcinoma. The present study evaluates the safety and efficacy of partial hepatectomy for intrahepatic recurrence after prior local ablation.

METHODS

A retrospective analysis was conducted of 188 consecutive patients with hepatocellular carcinoma who underwent either partial hepatectomy for recurrence after prior local ablation (n=13) or partial hepatectomy as initial local treatment (n=175). The 13 patients with recurrence after prior local ablation were referred to our division after the resectable recurrences were considered to be resistant to non-surgical treatment modalities.

RESULTS

The incidences of postoperative morbidity and mortality were similar for patients with prior local ablation and patients without prior local ablation (p=0.75 and p=0.52, respectively). The overall survival rates after hepatectomy were comparable between patients with prior local ablation (median survival time of 86months; cumulative 5-year survival rate of 63%) and patients without prior local ablation (median survival time of 76months; cumulative 5-year survival rate of 54%; p=0.60). The disease-free survival rates after hepatectomy were significantly worse for patients with prior local ablation based on both univariate (p=0.01) and multivariate (relative risk, 2.73; p<0.01) analyses.

CONCLUSIONS

Hepatectomy can be performed safely and may be efficacious, in terms of overall survival, for selected patients with intrahepatic recurrence after prior local ablation for hepatocellular carcinoma. On the other hand, prior local ablation appears to increase the probability of failure after hepatectomy.

Preoperative predictors of vascular invasion in hepatocellular carcinoma

AIMS

Vascular invasion is an established adverse prognostic factor in hepatocellular carcinoma (HCC). The aim of the current study was to identify the preoperative predictors of vascular invasion in patients undergoing partial hepatectomy for HCC.

METHODS

A retrospective analysis of 227 consecutive patients who underwent partial hepatectomy for HCC was conducted. Vascular invasion was defined as gross or microscopic involvement of the vessels (portal vein or hepatic vein) within the peritumoral liver tissue.

RESULTS

Seventy-six (33%) patients had vascular invasion. Among the preoperative factors, only the tumour size (relative risk, 16.78; p<0.01) and the serum alpha-fetoprotein (AFP) level (relative risk, 3.57; p<0.01) independently predicted vascular invasion. As the tumour size increased, the incidence of vascular invasion increased: < or =2 cm, 3%; 2.1-3 cm, 20%; 3.1-5 cm, 38%; and > 5 cm, 65%. The incidence of vascular invasion was 32% in patients with serum AFP levels < or =1000 ng/mL, compared to 61% in patients with higher serum AFP levels (p<0.01). Patients with both tumours >5 cm and serum AFP levels >1000 ng/mL had an 82% incidence of vascular invasion.

CONCLUSIONS

The tumour size and serum AFP level, alone or in combination, are useful in predicting the presence or absence of vascular invasion before hepatectomy for HCC.

Number of positive lymph nodes independently affects long-term survival after resection in patients with ampullary carcinoma

AIM

The nodal status is an established prognostic factor in ampullary carcinoma. The aim of this study was to compare the prognostic power of the anatomic location of positive nodes with that of the number of positive nodes.

METHODS

Of 73 consecutive patients treated for ampullary carcinoma, 62 underwent pancreaticoduodenectomy with regional lymphadenectomy. A survival analysis of these 62 patients by nodal status was conducted retrospectively. A total of 1942 lymph nodes taken from the patients were examined histologically for metastasis. The location of positive regional nodes was classified into 4 categories, according to the Japanese staging system. The number of positive regional nodes was recorded for each patient. The median follow-up period was 124 months.

RESULTS

Nodal disease was found in 31 patients, of whom 23 had 1-3 positive regional nodes and 8 had >or=4 positive regional nodes. Univariate analysis revealed that both the location (p<0.0001) and the number (p<0.0001) of positive nodes were significant prognostic factors. Multivariate analysis revealed that the number of positive nodes was an independent prognostic factor (p=0.007), while the location failed to remain as an independent variable. The median survival time was 59 months with a 5-year survival rate of 48% in patients with 1-3 positive nodes, whereas all patients with >or=4 positive nodes died of the disease within 29 months of resection (p=0.0001).

CONCLUSION

The number, not the location, of positive regional lymph nodes independently affects long-term survival after resection in patients with ampullary carcinoma.

87 EVALUATION OF MITOCHONDRIAL FUNCTION IN SINGLE CLONED MINIATURE PIG EMBRYOS BY MEASURING OXYGEN CONSUMPTION

Mitochondria are organelles that produce energy for embryogensis. Their function [oxidative phosphorylation (OXPHOS) and electron transport] is regulated by intercommunication with the nucleus. In somatic cell nuclear transfer (SCNT) embryos, incomplete reprogramming may lead to dysfunction of the intercommunication before or after embryonic activation, or both, although it is unknown whether reprogramming for energy synthesis is required. In the previous report (Abe et al. 2004 J. Mamm. Ova Rec. 21, 22), we developed a noninvasive method using a scanning electrochemical microscopy (SECM) for measurement of oxygen consumption that provides more direct information about mitochondrial function (Trimarch et al. 2000 Biol. Reprod. 62, 1866–1874). In the present study to evaluate mitochondrial function in individual miniature pig SCNT embryos, we measured oxygen consumption by SECM. Oocytes in pig ovaries collected from the local slaughterhouse were matured for 44 h in NCSU23 and used as recipient. After SCNT with fetal miniature pig fibroblasts, reconstructed embryos were cultured in vitro in NCSU23 or PZM-3. Oxygen consumption in single 2- and 4-cell-stage embryos, morulae, and blastocysts were measured, and the values were compared with those derived from IVF. All data were analyzed by ANOVA. In IVF embryos, oxygen consumption was lowest at the 2- and 4-cell stages, and reached a peak at the blastocyst stage on Day 5. However, there were significant differences (P &lt; 0.05) in blastocysts between NCSU23 and PZM-3: 0.61 � 0.14 vs. 0.83 � 0.18 at Day 5, 0.53 � 0.14 vs. 0.70 � 0.24 at Day 6, 0.47 � 0.11 vs. 0.73 � 0.20 � 10-14 mol s-1 at Day 7, respectively. In contrast, SCNT embryos showed no increase in oxygen consumption during pre-implantation stages in the 2 media, but there was a significant difference (P &lt; 0.05) at the 2-cell stage between NCSU23 and PZM-3 (0.35 � 0.09 vs. 0.43 � 0.10, respectively). Comparison of the Day 5 IVF and SCNT blastocysts cultured in PZM-3 showed no difference in total cell numbers but significantly (P &lt; 0.05) lower oxygen consumption in SCNT (0.83 � 0.18 vs. 0.40 � 0.13 � 10-14 mol s-1, respectively). After treatment with 1 �M CCCP (mitochondrial uncoupler) or 1 mM NaCN (mitochondrial electron transporter inhibitor), oxygen consumption in IVF and SCNT blastocysts at Day 5 increased (112 � 18 and 51 � 44%, respectively) or decreased (50 � 20 and 21 � 32%, respectively) compared with those of nontreated embryos. Sensitivity to these reagents differed significantly (P &lt; 0.05) between IVF and SCNT, indicating that the SCNT blastocysts had a lower OXPHOS capacity than those from IVF. These results suggest that reprogramming for sustaining mitochondrial function during pre-implantation development may be required in miniature pig SCNT embryos.

78 EFFECTS OF DIFFERENT ACTIVATION PROTOCOLS ON ACTIN FILAMENT DISTRIBUTION AND IN VITRO DEVELOPMENT OF MINIATURE PIG NT EMBRYOS

In the process of producing reconstructed oocytes nuclear transfer (NT) embryos by somatic cell nuclear transfer, in vitro-matured oocytes can be used as recipient ones. It, however, has been well documented that after IVF porcine embryos derived from in vitro-matured oocytes have a small number of cells and low viability compared from those in vivo. As one possible reason, abnormal actin filament distribution has been detected in abnormal embryo cleavage and small cell numbers (Wang et al. 1999 Biol. Reprod. 60, 1020-1028). Artificial activation, which is necessary for development of NT embryos, can affect actin filament distribution of porcine oocytes matured in vitro, resulting in fragmentation (Kawahara et al. 2002 Theriogenology 58, 1081-1095). In the present study, we investigated effects of different activation protocols on actin filament distribution and in vitro development of miniature pig NT embryos. Porcine oocytes collected from ovaries were matured in vitro for 40 to 44 h in NCSU-23. First, we compared different activation protocols in development rates to blastocysts of oocytes activated. We used three activation methods (15 �M ionomycin treatment for 20 min (I), double DC pulses of 1.2 kV/cm for 60 ms in intervals of 5 s (E), and 5 mg/mL cycloheximide treatment for 5 h (C)) to prepare seven activation protocols (I, E, C, I + C, I + E, E + C, and I + E + C). Second, we examined effects of different activation protocols on actin filament distribution and subsequent development of NT embryos activated by the different activation protocols. Matured oocytes were enucleated, and fused with miniature pig fetal fibroblasts in calcium-free medium; approximately 3 h later, the resultant NT embryos were activated with three activation protocols (E, I + C, or I + E + C). All data were analyzed by chi-square test. The developmental rates to blastocysts in the I, E, C, I + C, I + E, E + C, and I + E + C groups were 5.6, 11.1, 0.0, 36.1, 20.7, 14.6, and 24.7%, respectively, showing that the rate in oocytes activated with I + C was significantly higher (P < 0.05) than the rates in oocytes activated by other treatments. In NT embryos, the developmental rates to blastocysts in the E, I + C, or I + E + C groups were 4.1, 14.3, and 4.6%, respectively, showing that the rate in NT embryos activated with I + C was significantly higher (P < 0.05) than the rate in NT embryos activated with other treatments. The abnormal rate of actin filament distribution in NT embryos activated with E or I + E + C was significantly higher (P < 0.05) than that in NT embryos activated with I + C (26.7% or 33.3% vs. 6.7%). The present results suggest that in miniature pig NT embryos an activation protocol by ionomycin combined with cycloheximide treatments may avoid physical damage to actin filaments with the resultant improvement of subsequent development.

High risk of gallbladder carcinoma in elderly patients with segmental adenomyomatosis of the gallbladder

The clinical significance of adenomyomatosis of the gallbladder remains unclear. This study aimed to clarify the relationship between segmental adenomyomatosis and gallbladder carcinoma, and to elucidate the histogenesis of gallbladder carcinoma associated with segmental adenomyomatosis. A total of 4,560 consecutive patients underwent cholecystectomy. The specimens were examined grossly and histologically. Adenomyomatosis of the gallbladder was divided into segmental, fundal, and diffuse types. Sixty noncancerous gallbladders with segmental adenomyomatosis were examined for epithelial metaplasia. The incidence of gallbladder carcinoma was higher in patients with segmental adenomyomatosis (22/334, 6.6%) than in those without (181/4226, 4.3%; P=0.049). This difference was more marked among patients equal to or older than 60 years of age (15/96,15.6% versus 147/2407, 6.1%, respectively; P<0.001). The other types of adenomyomatosis did not show any significant increases in the incidence of gallbladder carcinoma. In all 22 patients with both segmental adenomyomatosis and carcinoma, the tumors developed only in the fundal mucosa. Epithelial metaplasia was more marked in the fundal mucosa of segmental adenomyomatosis than in the neck mucosa (P=0.003). Segmental adenomyomatosis is a high-risk condition for gallbladder carcinoma, especially in elderly patients. Epithelial metaplasia appears to be related to increased carcinogenesis in the fundal mucosa of segmental adenomyomatosis.

Late resistance to imatinib therapy in a metastatic gastrointestinal stromal tumour is associated with a second KIT mutation

Currently, there are no data on the secondary resistance of gastrointestinal stromal tumours to imatinib. Here, we report a case of metastatic gastrointestinal stromal tumour that relapsed during imatinib therapy. Mutation analysis showed that the imatinib-resistant liver tumour contained two c-kit mutations.

Hepatitis viral status affects the pattern of intrahepatic recurrence after resection for hepatocellular carcinoma

AIM

To define whether the patterns of intrahepatic recurrence after resection for hepatocellular carcinoma differ according to hepatitis viral status.

METHODS

One hundred and eleven patients undergoing a curative resection for hepatocellular carcinoma were divided into three groups: the C-viral group (n=55), which tested positive for hepatitis C antibody; the B-viral group (n=32), which tested positive for hepatitis B surface antigen; and the non-B non-C (NBNC) group (n=24), which tested negative for both hepatitis B surface antigen and hepatitis C antibody. The long-term outcomes were analyzed retrospectively.

RESULTS

The pattern of development of intrahepatic recurrence differed between the NBNC group and the other groups: the cumulative probability of intrahepatic recurrence reached a plateau at 2.4 years after resection in the NBNC group, while it continued to increase steadily in the hepatitis viral groups. The C-viral group showed a higher incidence of intrahepatic recurrence than the other groups by univariate (P=0.0306) and multivariate (relative risk=1.69, P=0.0429) analyses. Multiple intrahepatic recurrent lesions were more common in the C-viral group (P=0.0457).

CONCLUSIONS

Multicentric carcinogenesis in the remnant liver was less common in the NBNC group than in hepatitis viral groups. Hepatitis C virus infection is a significant risk factor for intrahepatic recurrence after resection and is also associated with multiple intrahepatic recurrent lesions.

Computed tomographic features of hepatocellular carcinoma predict long-term survival after hepatic resection

AIM

To evaluate the potential of computed tomographic features of hepatocellular carcinoma as prognostic factors.

METHODS

Medical records for 112 patients who had undergone a partial hepatectomy for hepatocellular carcinoma were retrospectively analyzed. The largest hepatic tumour in each patient was classified by pre-operative computed tomographic features as lobular configurations with indentations showing an acute angle, or non-lobular configuration without such indentations.

RESULTS

Twenty-six tumours were lobular and 86 were non-lobular. The outcome after hepatectomy was significantly worse in patients with lobular tumours (cumulative 5-year survival rate of 19.9%) than with non-lobular ones (that of 75.2%) (P<0.001). Cox's proportional hazards model showed computed tomographic features (P=0.0025), cirrhosis (P=0.0033), and tumour size (P=0.0412) to be independent prognostic factors. A lobular configuration was associated with satellite nodules (P<0.001), portal vein invasion (P=0.021), and extrahepatic tumour relapse (P=0.006).

CONCLUSIONS

Computed tomographic features represent a strong prognostic factor in patients undergoing partial hepatectomy for hepatocellular carcinoma, and are likely to accurately reflect the tumour biology. Configuration, size of the hepatic tumour and presence of cirrhosis are the most important prognostic imaging findings in these patients.

Early gallbladder carcinoma does not warrant radical resection

BACKGROUND

This study was designed to address whether gallbladder cancer invading the muscle layer (stage pT(1b)) is a local disease and whether radical resection is necessary.

METHODS

A retrospective analysis of 25 patients with pT(1b) gallbladder tumours, 13 of whom underwent simple cholecystectomy and 12 radical resection with regional lymph node dissection, was performed. A total of 147 regional lymph nodes was examined for metastasis. The median follow-up time was 95 months.

RESULTS

No patient had blood vessel or perineural invasion on histology. Lymphatic vessel invasion was seen in one patient. Both overt metastasis and micrometastases were absent in all lymph nodes examined. Overall 10-year survival was 87 per cent. The outcome after simple cholecystectomy was comparable to that after radical resection (P = 0.16). Two patients who underwent radical resection died from tumour relapse in distant sites.

CONCLUSION

Most pT(1b) gallbladder carcinomas spread only locally. Additional radical resection is not necessary when the depth of invasion of gallbladder carcinoma is limited to the muscle layer after simple cholecystectomy.

Anomalous insertion of the right hepatic duct into the cystic duct: report of a case diagnosed before laparoscopic cholecystectomy

Although an aberrant hepatic duct entering the cystic duct is not especially rare, the main right hepatic duct entering the cystic duct is extremely rare, with only six cases reported thus far. All of the reported patients underwent open cholecystectomy, during which one patient received a bile duct injury. The anomaly was unsuspected preoperatively in all of these cases. We report an additional patient with this anomaly, the first such case diagnosed before laparoscopic cholecystectomy using direct cholangiography. Cholangiography may be mandatory whenever biliary anomalies are suspected during laparoscopic cholecystectomy. As the right hepatic duct entering the cystic duct can lead to ductal injury, this anomaly should be kept in mind when performing laparoscopic cholecystectomy.

Malignant fibrous histiocytoma metastases to the small intestine and colon presenting as an intussusception

A case of malignant fibrous histiocytoma metastases to the small intestine and colon presenting as an intussusception is described. Although malignant fibrous histiocytoma is the most common soft tissue sarcoma in late adult life, GI involvement has rarely been reported. The review of both our case and eight cases in the English-language literature suggests that GI involvement from malignant fibrous histiocytoma occurs most frequently in the small intestine (six of nine) and that two major clinical manifestations of GI involvement are GI bleeding (five of nine) from ulcerated tumors and intussusception (two of nine) led by polypoid tumors.

Protein kinase C controls the priming step of regulated exocytosis in adrenal chromaffin cells

1. To investigate the mechanism whereby protein kinase C enhances secretory function in adrenal chromaffin cells, we examined the effects of 12-O-tetradecanoylphorbor-13-acetate (TPA) on Ca(2+)-induced catecholamine release from digitonin-permeabilized cells, resolving the release into a MgATP-dependent priming step and a MgATP-independent Ca(2+)-triggered step. Treatment with TPA selectively potentiated the priming activity of MgATP, with little increase in the MgATP-independent release. The potentiation by TPA of the MgATP-dependent priming was blocked by [Ser25]protein kinase C(19-31), a specific substrate of protein kinase C. Gö 6976, an inhibitor selective for protein kinase C alpha and beta isoforms, also blocked the potentiation by TPA. These results suggest that activation of protein kinase C, probably the alpha isoform, potentiates the MgATP-dependent priming step. 2. The antibody raised against GAP-43, a known substrate of protein kinase C, also potentiated the MgATP-dependent priming. The effect of TPA and that of the anti-GAP-43 antibody were not additive. Calmodulin, which binds to GAP-43 and inhibits its phosphorylation by protein kinase C, abolished the effect of TPA. Thus, the present results suggest that protein kinase C potentiates MgATP-dependent priming, at least in part, through phosphorylation of GAP-43.

Decreases in peripheral-type benzodiazepine receptors in postmortem brains of chronic schizophrenics

We measured the peripheral-type benzodiazepine receptors (PBRs), a marker of gliosis, in 26 brain areas (cerebral cortex, thalamus and extrapyramidal system) of the postmortem brains of 13 chronic schizophrenics and 10 controls, using [3H] PK 11195 as a ligand for the receptor assay. The specific [3H] PK 11195 binding was significantly decreased in three brain areas (superior parietal cortex, primary visual area and putamen) of schizophrenics, although there were no changes in the binding in the other brain areas. Scatchard analysis revealed that there were decreases in both the Bmax and Kd of [3H] PK 11195 binding in the brain areas. These results were almost in accordance with a number of neuropathological studies reporting that there was no change or reduction in glial cells in the brain regions of schizophrenics and suggested that the decreased density of PBRs in the brain may be involved in the pathophysiology of schizophrenia, associated with reduced production of neurosteroids coupled to PBRs.

Hepatocellular carcinoma associated with precirrhotic primary biliary cirrhosis successfully treated by a right hepatic lobectomy: report of a case

We report herein the case of a 69-year-old woman in whom hepatocellular carcinoma (HCC) arising in the precirrhotic phase of primary biliary cirrhosis (PBC) was successfully managed by a right hepatic lobectomy. The patient, who had never received a blood transfusion, had a 4-year history of asymptomatic PBC of Scheuer's histological classification stage II. Abdominal computed tomography (CT) revealed a mass measuring 4.0 cm in the right hepatic lobe, and a right hepatic lobectomy was performed in consideration of her good liver function and the deep location of the tumor in the right lobe. The patient has remained well without any evidence of recurrent disease for 4 years since her operation. A review of the literature revealed only two cases of successful partial hepatectomy, but none of major hepatectomy. Most of the reported cases had been treated with transcatheter arterial embolization (TAE) and were associated with poor survival. Our experience of this patient indicates the potential value of hepatectomy as an alternative to TAE in selected patients with resectable disease and good hepatic function.

Colorectal carcinoma metastases to the liver. Does primary tumor location affect its lobar distribution?

BACKGROUND

There is considerable evidence that blood returning from different abdominal organs does not mix completely but maintains streamline flow in the portal vein. This study tested the hypothesis that the location of primary colorectal carcinoma affects the intrahepatic distribution of liver metastases according to streamline flow in the portal vein.

METHODS

Eighty-five patients with histologically verified liver metastases from colorectal carcinoma underwent potentially curative hepatectomy. Primary tumor location was the right-sided colon in 18 patients and the left-sided colon in 67. The liver was divided into two lobes by Cantlie's line.

RESULTS

A total of 195 metastatic deposits were resected: 135 in the right lobe and 60 in the left. In the right-sided colon carcinoma group, 29 deposits were in the right lobe and 3 in the left. In the left-sided colon carcinoma group, 106 deposits were in the right lobe and 57 in the left. The pattern of lobar distribution was significantly different in the two groups (P = 0.003).

CONCLUSIONS

Right-sided colon cancers selectively involve the right lobe, while left-sided tumors involve the entire liver, considering the ratio of weights of the right to left lobe is 2:1. This difference suggests that primary tumor location affects the pattern of lobar distribution of colorectal carcinoma liver metastases according to streamline flow in the portal vein.

[Maternal carriage and vertical transmission of group B Streptococcus (GBS)]

The pneumonia, sepsis and meningitis are common diseases of GBS infection in infants. There are early-onset and late-onset types in this disease, the result of the infection is unknown. M. Sugiyama reported that M9 is a new type of GBS in Japan in 1989. Analysis of GBS typing and serum specific antibody concentrations of the type are simple with new technics. By studying the infants' contamination we discovered that GBS appeared to originate from mother-infant sources. The infants were followed for a year. 52% of the infants had GBS contamination in their throat or stool. The most common type was Ia, followed by III, JM9 and NT6. Those types without III type had been present for more than 9 months in the infant. The contamination term of Ia or III type in infants correlated with the blood specific antibody concentration of the type.

[Occurrence of Escherichia coli in urinary tract infection]

Regarding P-fimbriae, K1 antigen, sero O-type and factors on the host (age, sex and morbidity) with are the pathogenic factors in E. coli, an assessment has been made as to what relations these factors have in urinary tract infection. By age, cases of P-fimbriae is seen in large numbers among pregnant women and infants but less among the people aged 16-30. A similar trend was observed regarding K1 antigen. An assessment made by sex show a trend that E. coli which carries P-fimbriae tends to emerge frequently in males. By morbidity, P-fimbriated strain was seen in many severe cases among pregnant women and infants. The fact has become evident further as a result of making an investigation with K1 antigen added. However, the result of an assessment made in adult cases showed that P-fimbriae was seen frequently in simple cystitis conversely. As the reason for P-fimbriae being observed more in males, participations of immunological stage and anatomical factors on the host side in the pathogenicity was resumed, and the main cause that P-fimbriae is seen more in severe pregnant and infantile cases was presumed to be vesicoureteral reflux. Regarding group sero O-type and morbidity, the types reported so far were detected also at our hospital, but a very interesting finding we have obtained was that the stains P-fimbriae and K1 antigen were observed in types 2, 12, 18 and 75.

Purification of rat prolactin releasing factor by gel filtration

Pregnant rat hypothalamic fragments were extracted with 30 mM Tris-HCl buffer at pH 7.8, subjected to enzymatic digestion, and applied to gel filtration on Sephadex G-25 for purification of the prolactin releasing factor. Effect of the eluted fractions on the release of prolactin were tested by the determination of serum and pituitary prolactin after the injection in lactating rats. Prolactin was estimated by radioimmunoassay. One fraction (tube number 61--73) eluted later than synthetic ACTH enhanced release of prolactin 30 min after injection, but other fractions had no effect on the release of prolactin. Prolactin releasing factor would be quantitatively predominant over prolactin inhibiting factor in pregnant rat.

Relationship between prolactin secretion and hypothalamic prolactin releasing factor in pregnant and puerperium rats

The present study attempted to elucidate stimulatory factor(s) in the rat hypothalamus which controls prolactin secretion from the anterior pituitary. Rat serum prolactin was elevated so much in late pregnancy that we prepared the hypothalamic extract of late pregnant rats. Prolactin levels in serum and pituitary by radioimmunoassay. After injection of this extract into a lactating rat 48-60 hr after delivery, the serum prolactin level was elevated significantly one to four hr later and the pituitary prolactin level declined two hr later. On the other hand, the hypothalamic extract of normal female rats prepared in a similar manner inhibited prolactin secretion from the anterior pituitary in the lactating rat as described by other authors. These data indicate that the prolactin releasing factor may consist in the hypothalamus of late pregnant rat, and be predominant over the prolactin inhibiting factor during late pregnancy. Prolactin secretion was also investigated in lactating and non-lactating puerperium rats. Prolactin in serum and pituitary declined with days after delivery in non-lactating rats, but not in lactating rats. The presumed factor for such prolactin release in lactating rats is considered to be the prolactin releasing factor.

[Prolactin releasing action of the hypothalamic extract in last stage of pregnant rats (author's transl)]

Regulation of prolactin secretion in pituitary is considered to be mostly carried with the action of prolactin inhibiting factor in hypothalamus. We have investigated on the subject of prolactin releasing factor in the hypothalamus of rats in last stage of pregnancy using puerperal and ovariectomized rats as recipients. After prepared the cell-free system of pregnant rat hypothalamus with sonic oscillator, supernatant was produced by ultracentrifuge (25,000 X g, 30 min.) and utilized for the experiments. When the extract was injected intramuscularly to puerperal rats (48-60 hours after delivery), serum prolactin values increased gradually to 3 times of control values, but pituitary prolactin values showed the variation with decrease and recovery. The control values were obtained by determination after injection of cerebral cortical extract to puerperal rats. After administration of a extract of non-pregnant rat hypothalamus to puerperal rats, serum prolactin values decreased and pituitary prolactin values increased antagonistically. In the ovariectomized rats pretreated with estradiol and progesterone, serum prolactin values increased in 1 hour after administration of the extract of pregnant rat hypothalamus, but pituitary prolactin values did not show any variation. The present experiment suggests that the prolactin secretion promoting factor exists in the hypothalamus of pregnant rats and predominates over as compared with PIF in last stage of pregnancy.