The cholinesterase and C-reactive protein score is a potential predictor of pseudoaneurysm formation after pancreaticoduodenectomy in patients with soft pancreas

BACKGROUND

Pseudoaneurysm (PA) rupture after pancreaticoduodenectomy (PD) is a life-threatening complication. Most PA cases originate from postoperative pancreatic fistulas (POPFs). Although several risk factors for POPF have been identified, specific risk factors for PA formation remain unclear. Therefore, we retrospectively analyzed PD cases with soft pancreas and proposed a novel strategy for early detection of PA formation.

METHODS

Overall, 120 patients underwent PD between 2010 and 2020 at our institution; of these, 65 patients with soft pancreas were enrolled. We evaluated the clinicopathological factors influencing PA formation and developed a risk score to predict PA formation.

RESULTS

In total, 11 of the 65 patients developed PAs (PA formation group: PAG), and 8 of these 11 PAs ruptured. The median time to PA formation was 15 days, with a minimum of 5 days. The PAG was significantly older than the non-PA formation group, were predominantly men, and had comorbid diabetes mellitus. Pre- and intra-operative findings were similar between the two groups. Importantly, no significant differences were found in postoperative drain amylase levels and total drain amylase content. Cholinesterase and C-reactive protein (CRP) levels on postoperative day (POD) 3 were significantly different between the two groups. Multivariate analysis showed that cholinesterase ≤ 112 U/L and CRP ≥ 16.0 mg/dl on POD 3 were independent predictors of PA formation.

CONCLUSIONS

Decreased cholinesterase and elevated CRP on POD 3 (Cho-C score) are useful predictors of PA formation in cases with soft pancreas. In such cases, periodic computed tomography evaluations and strict drain management are necessary to prevent life-threatening hemorrhage.

Measurement of Direct-Photon Cross Section and Double-Helicity Asymmetry at sqrt[s]=510 GeV in p[over →]+p[over →] Collisions

We present measurements of the cross section and double-helicity asymmetry A_{LL} of direct-photon production in p[over →]+p[over →] collisions at sqrt[s]=510  GeV. The measurements have been performed at midrapidity (|η|<0.25) with the PHENIX detector at the Relativistic Heavy Ion Collider. At relativistic energies, direct photons are dominantly produced from the initial quark-gluon hard scattering and do not interact via the strong force at leading order. Therefore, at sqrt[s]=510  GeV, where leading-order-effects dominate, these measurements provide clean and direct access to the gluon helicity in the polarized proton in the gluon-momentum-fraction range 0.02<x<0.08, with direct sensitivity to the sign of the gluon contribution.

Gallbladder perforation following peroral cholangioscopy-guided lithotripsy: A case report

Peroral cholangioscopy-guided lithotripsy is highly effective in clearing difficult bile duct stones. It can cause adverse events, such as cholangitis and pancreatitis; however, gallbladder perforation is extremely rare. Herein, we describe the case of a 77-year-old woman who developed gallbladder perforation following peroral cholangioscopy -guided lithotripsy. She was referred to our hospital to treat multiple large bile duct stones. She underwent peroral cholangioscopy-guided lithotripsy because of conventional lithotripsy failure. After a cholangioscope was advanced into the bile duct, saline irrigation was used for visualization. Electronic hydraulic lithotripsy was performed, but it took time for fragmentation because the calculus was hard. The 2-h endoscopic procedure did not completely remove the stone, and treatment was discontinued after placing a biliary plastic stent and nasobiliary tube. After the endoscopic procedure, she started experiencing right hypochondrial pain, which worsened the next day. Computed tomography showed a gallbladder wall defect in the gallbladder fundus with pericholecystic fluid. She was diagnosed with gallbladder perforation and underwent emergency surgery. A perforation site was found at the gallbladder fundus. Open cholecystectomy, choledochotomy, and extraction of residual bile duct stones were performed. The patient was discharged 9 days post-surgery without any complications. The saline irrigation used for visualization may have caused a surge in intra-gallbladder pressure, resulting in gallbladder perforation. Therefore, endoscopists may need to conserve irrigation water during peroral cholangioscopy-guided lithotripsy.

Analysis of external pressure on the left calf in the Lloyd-Davies position during colorectal surgery

PURPOSE

Well-leg compartment syndrome (WLCS) is a potentially life-threatening postoperative complication related to the Lloyd-Davies surgical position, which can place increased external pressure on the calf region. We conducted this study to analyze external pressure changes, by applying a leg holder system to the left calf region of patients placed in the Lloyd-Davies position during laparoscopic surgery.

METHODS

The study participants were 50 patients who underwent laparoscopic surgery for colorectal cancer in the Lloyd-Davies position. We assessed the maximum external pressure (MEP) on the left calf region using a pressure-distribution measurement system. Intraoperative measurements were taken continuously, and the MEP was evaluated with the patient horizontal and every 30 min during surgery in the head and right-down tilt position.

RESULTS

The intraoperative MEP increased gradually when the patient was in the head and right-down tilt position and decreased when the patient was returned to the horizontal position. The MEP was higher in patients aged < 60 years, those who were obese, and those with a thick calf circumference. Both body mass index (BMI) and the maximum left calf circumference (MLCC) were found to correlate with the MEP.

CONCLUSIONS

In addition to a high BMI, which is a well-known risk factor for WLCS, a high MLCC should be considered another risk factor, especially for patients under 60 years.

Early enteral nutrition with arginine compensates for negative nitrogen balance in patients undergoing curative total gastrectomy

The effects of early enteral arginine-rich nutrition (EAN) were analyzed among patients undergoing curative-intent total gastrectomy for gastric cancer. There were 19 patients in this prospective study, all randomly assigned to either a parenteral nutrition (PN) group or an EAN group for the first seven days after surgery. The EAN group received 1.8-fold greater arginine (10.1 g/day) compared with the PN group, which was administered through an enteral tube inserted into the jejunal loop. Both groups were provided almost identical amounts of total amino acids (54 g/day), and the total energy was set at 65% of the total requirement (25 kcal/kg/day). No significant differences were observed between the two groups in postoperative complications, length of hospital stay, oral intake, nutritional status, or body weight. The serum arginine profile was similar in the two groups, as it decreased significantly on postoperative day (POD) 1, and gradually returned to preoperative levels by POD 7. The nitrogen balance remained negative until POD 7 in the PN group, but turned neutral at POD 7 in the EAN group. While we could not confirm body weight loss improvement, these results suggested that early arginine-rich enteral nutrition could improve the nitrogen balance after total gastrectomy. J. Med. Invest. 70 : 325-333, August, 2023.

Comprehensive evaluation of three-dimensional anatomy of perigastric vessels using enhanced multidetector-row computed tomography

BACKGROUND

To perform laparoscopic gastrectomy safely, we aimed to comprehensively re-evaluate perigastric vessel anatomies using a three-dimensional angiography reconstructed from enhanced multidetector-row computed tomography data.

METHODS

Perigastric vessel anatomy was preoperatively analyzed using a multidetector-row computed tomography-based three-dimensional angiography reconstructed in 127 patients undergoing gastric surgery.

RESULTS

Of the 67 left gastric veins that ran along the dorsal side of the arteries, 59 (88.1%) ran along the dorsal side of the common hepatic artery and flowed into the portal vein. In 18 cases, a common trunk of one to three left gastric arteries and the replaced left hepatic artery was observed. The left inferior phrenic artery ramified from the left gastric artery in 5.5% of the cases. The right gastric artery was classified into distal (73.2%), caudal (18.1%), and proximal (8.7%) types. The infra-pyloric artery was also classified into distal (64.6%), caudal (26.0%), and proximal (9.4%) types. The posterior gastric artery branched as a common trunk with the superior polar artery in the proximal (37.9%) and distal (18.4%) regions of the splenic artery. The left gastroepiploic artery ramified from the splenic (18.1%) and inferior terminal arteries (81.9%). No, one, and two gastric branches of the left gastroepiploic artery, which ramified between the roots of the left gastroepiploic artery and its omental branch, were found in 36.5%, 49.2%, and 14.3% of the cases, respectively.

CONCLUSIONS

Preoperative 3D angiography is useful for the precise evaluation of perigastric vessel anatomies, and may help us to perform laparoscopic gastrectomy and robotic surgery safely.

Saturated Fatty Acids in Cell Membrane Lipids Induce Resistance to 5-Fluorouracil in Colorectal Cancer Cells

BACKGROUND/AIM

Resistance to chemotherapy is a major obstacle for patients with unresectable colorectal cancer (CRC); however, the factors that induce chemoresistance have not been elucidated. Lipid composition influences neoplastic behaviour. Therefore, this study examined whether lipid composition affects sensitivity to chemotherapeutic agents in CRC.

MATERIALS AND METHODS

We performed a lipidomic analysis of a CRC xenograft-derived spheroid model to identify potential relationships between the lipid profile and chemoresistance to 5-fluorouracil (5-FU). Genetic and pharmacological modulation of lipid synthesis were also used in the HCT-116 and DLD-1 CRC cell lines to further characterize resistance to 5-FU.

RESULTS

Our lipidomic profiling revealed that phospholipids with saturated fatty acids (SFAs) were more abundant in 5-FU-resistant spheroids. The importance of phospholipids containing SFA in chemoresistance was confirmed by showing that in HCT-116 and DLD-1 cells, genetic or pharmacological inactivation of stearoyl-CoA desaturase-1, a key enzyme that converts SFAs to monounsaturated fatty acids, increased the proportion of SFAs in membranous phospholipids and reduced cell membrane fluidity, and this ultimately resulted in resistance to 5-FU.

CONCLUSION

These data suggest that the saturated to monounsaturated fatty acid ratio in cellular membranous phospholipids affects sensitivity to chemotherapeutic agents.

Emergency appendectomy versus elective appendectomy following conservative treatment for acute appendicitis: a multicenter retrospective clinical study by the Japanese Society for Abdominal Emergency Medicine

PURPOSE

To establish the best treatment strategy for acute appendicitis.

METHODS

We collected data on 2142 appendectomies performed in 2017 and compared the backgrounds and surgical outcomes of patients who underwent early surgery (ES) (< 48 h) with those managed with non-ES (> 48 h). We performed a risk factor analysis to predict postoperative complications and subgroup analysis to propose a standard treatment strategy.

RESULTS

The incidence of postoperative complications was significantly higher in the ES group than in the non-ES group, and significantly lower in the laparoscopic surgery group than in the laparotomy group. Surgical outcomes, including the incidence of postoperative complications, were comparable after acute surgery (< 12 h) and subacute surgery (12-48 h), following antibiotic treatment. The risk factors for postoperative complications in the ES group were a higher age, history of abdominal surgery, perforation, high C-reactive protein level, histological evidence of gangrenous or perforated appendicitis, a long operation time, and intraoperative complications. The risk factors for postoperative complications in the non-ES group were perforation and unsuccessful conservative treatment.

CONCLUSIONS

Non-early appendectomy is feasible for acute appendicitis but should be applied with care in patients with risk factors for postoperative complications or failure of pretreatment, including diabetes mellitus, abscess formation, and perforation.

Comparison of operative outcomes between monopolar and bipolar coagulation in hepatectomy: a propensity score-matched analysis in a single center

Background

Various hemostatic devices have been utilized to reduce blood loss during hepatectomy. Nonetheless, a comparison between monopolar and bipolar coagulation, particularly their usefulness or inferiority, has been poorly documented. The aim of this study is to reveal the characteristics of these hemostatic devices.

Methods

A total of 264 patients who underwent open hepatectomy at our institution from January 2009 to December 2018 were included. Monopolar and bipolar hemostatic devices were used in 160 (monopolar group) and 104 (bipolar group) cases, respectively. Operative outcomes and thermal damage to the resected specimens were compared between these groups using propensity score matching according to background factors. Multivariate logistic regression analysis was performed to identify predictive factors for postoperative complications.

Results

After propensity score matching, 73 patients per group were enrolled. The monopolar group had significantly lower total operative time (239 vs. 275 min; P = 0.013) and intraoperative blood loss (487 vs. 790 mL; P < 0.001). However, the incidence rates of ascites (27.4% vs. 8.2%; P = 0.002) and grade ≥ 3 intra-abdominal infection (12.3% vs. 2.7%; P = 0.028) were significantly higher in the monopolar group. Thermal damage to the resected specimens was significantly longer in the monopolar group (4.6 vs. 1.2 mm; P < 0.001). Use of monopolar hemostatic device was an independent risk factor for ascites (odds ratio, 5.626, 95% confidence interval 1.881–16.827; P = 0.002) and severe intra-abdominal infection (odds ratio, 5.905, 95% confidence interval 1.096–31.825; P = 0.039).

Conclusions

Although monopolar devices have an excellent hemostatic ability, they might damage the remnant liver. The use of monopolar devices can be one of the factors that increase the frequency of complications.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-022-02231-y.

Probing Gluon Spin-Momentum Correlations in Transversely Polarized Protons through Midrapidity Isolated Direct Photons in p^{↑}+p Collisions at sqrt[s]=200 GeV

Studying spin-momentum correlations in hadronic collisions offers a glimpse into a three-dimensional picture of proton structure. The transverse single-spin asymmetry for midrapidity isolated direct photons in p^{↑}+p collisions at sqrt[s]=200  GeV is measured with the PHENIX detector at the Relativistic Heavy Ion Collider (RHIC). Because direct photons in particular are produced from the hard scattering and do not interact via the strong force, this measurement is a clean probe of initial-state spin-momentum correlations inside the proton and is in particular sensitive to gluon interference effects within the proton. This is the first time direct photons have been used as a probe of spin-momentum correlations at RHIC. The uncertainties on the results are a 50-fold improvement with respect to those of the one prior measurement for the same observable, from the Fermilab E704 experiment. These results constrain gluon spin-momentum correlations in transversely polarized protons.

Comprehensive strategy for perioperative care of pancreaticoduodenectomy according to the risk stratification by pancreatic fistula and delayed gastric emptying

BACKGROUND/OBJECTIVE

Pancreaticoduodenectomy (PD) is highly invasive with unsatisfactory postoperative complication rates. Nutritional and fluid management after major surgery attracts much attention with regard to the reduction in severe postoperative complications. We retrospectively analyzed PD cases and proposed a novel strategy for perioperative fluid and nutritional therapy according to the risk stratification by pancreatic fistula (PF) and delayed gastric emptying (DGE).

METHODS

Between 2003 and 2018, 140 patients underwent PD at our institute of which 134 patients were enrolled. We evaluated the clinicopathological factors affecting severe (≥10%) body weight loss (BWL), factors affecting the incidence of PF and intraabdominal complications (IAC), and factors related to DGE.

RESULTS

Multivariate analysis indicated that male sex, severe PF, and DGE are significant risk factors for BWL ≥10%. PF and IAC were predominantly observed in male patients and those with non-pancreatic cancer. A fluid balance ≥6000 ml on postoperative day 2 was the sole risk factor for primary DGE. Secondary DGE significantly correlated with stomach preserving PD. Importantly, the average BWL was around 15% in grade B or C secondary DGE.

CONCLUSION

Severe postoperative complications resulted in significant BWL. Enteral feeding is unnecessary in cases with a hard pancreas and dilated pancreatic duct if appropriate perioperative fluid management is performed. Secondary DGE followed by PF or IAC is unavoidable to some extent, especially in the case of soft pancreas with a fine pancreatic duct. In such cases, enteral feeding with tube ileostomy should be considered, and stomach preserving PD is likely to be harmful.

Multimodal therapy with surgery and adjuvant nivolumab for late-onset multiple liver metastases of choroidal malignant melanoma: a case report

BACKGROUND

Choroidal malignant melanoma is the most common primary malignant tumor of the eye in adults. Prognosis after recurrence of this disease has been dismal because of the absence of an effective therapy. However, resection of recurrent foci and a subsequent treatment with immune-checkpoint inhibitor may improve the prognosis after recurrence of this disease. This study presents a case of late-onset liver metastases of choroidal malignant melanoma, successfully treated with hepatectomy and postoperative adjuvant nivolumab.

CASE PRESENTATION

A 53-year-old woman had undergone left ocular enucleation because of choroidal malignant melanoma 13 years prior to admission. She visited a nearby clinic with complaints of epigastric pain. She was referred to our hospital because a giant liver tumor was observed on abdominal ultrasonography. Enhanced computed tomography revealed multiple liver tumors in the right lobe, 49 mm in diameter with ring enhancement in subsegment (S) 5/6, and 14 and 8 mm without any enhancement in S7 and S5, respectively. On magnetic resonance imaging, the main tumor showed high intensity on T1-weighted with fat suppression, suggesting melanin deposition. Based on the diagnosis of multiple liver metastases of choroidal malignant melanoma, right hepatectomy and regional lymphadenectomy were performed. She was discharged without postoperative complications. Histological examination revealed that all tumors were metastatic malignant melanoma. She was treated with nivolumab postoperatively, and no recurrences were observed during 22 months of follow-up.

CONCLUSIONS

Aggressive surgery plus adjuvant nivolumab appears to be a promising treatment for choroidal malignant melanoma with late-onset liver metastases.

Erratum: Evolution of π^{0} Suppression in Au+Au Collisions from sqrt[s_{NN}]=39 to 200 GeV [Phys. Rev. Lett. 109, 152301 (2012)]

This corrects the article DOI: 10.1103/PhysRevLett.109.152301.

Aggressive Recurrent Pancreatic Cancer Producing Granulocyte Colony-Stimulating Factor

Granulocyte colony-stimulating factor (G-CSF) is a glycoprotein which stimulates the proliferation, differentiation, and functional activation of myeloid hematopoietic cells. G-CSF-producing pancreatic cancer is rare and its prognosis is strikingly poor. A 69-year-old woman with well-to-moderately differentiated ductal adenocarcinoma (pT3N0M0, stage IIA) underwent distal pancreatectomy and splenectomy. Postoperative adjuvant chemotherapy with S-1 was administered for 6 months. Eleven months after surgery, periodic blood examination revealed remarkable leukocytosis (19,120/µL) without fever, which worsened 3 weeks later (36,160/µL). Furthermore, laboratory data showed elevation of the fibrin degradation product-D dimer and that the G-CSF level was high (406 pg/mL), as well as thrombopenia. Multiple liver and lung metastases were detected by contrast-enhanced computed tomography (CT). The patient was treated with gemcitabine plus nab-paclitaxel, and heparin, thrombomodulin alfa, and platelet transfusion were administered concurrently. Leukocytosis and thrombopenia were alleviated after 1 course of chemotherapy. However, remarkable leukocytosis (53,480/µL) recurred on day 1 of the third course of chemotherapy. Contrast-enhanced CT showed a significantly increased number of liver metastases and lung metastases. The patient chose not to receive second-line chemotherapy and died 1 month later at the affiliated hospital. Pancreatic cancer producing G-CSF shows very aggressive behavior. Leukocytosis without infection during routine observation should be considered as a warning of a rapidly growing recurrence.

Usefulness of laparoscopic narrow-band imaging for the evaluation of therapeutic effects on peritoneal metastasis in gastric cancer

287

Background: As recent advances in chemotherapy improved prognosis of gastric cancer (GC) patients with peritoneal metastasis (PM), accurate diagnosis of PM has become more important. However, the sensitivity of conventional imaging modalities such as CT or PET is not satisfactory. Staging laparoscopy (SL) is often used to diagnose PM in advanced GC patients, but accurate detection of PM can be difficult. In this study, we evaluate the usefulness of laparoscopic narrow-band imaging (NBI) versus conventional laparoscopic white-light imaging (WLI) for the diagnosis of PM and for the evaluation of therapeutic effect of chemotherapy. Methods: We excised 54 white nodules from the parietal peritoneum of 40 GC patients. Among them, 9 patients received chemotherapy for advanced or recurrent GC before SL, and 31 did not receive chemotherapy except for adjuvant chemotherapy with S-1. The WLI and NBI findings were compared with the pathological findings. Results: Intranodular vessels were evaluated by WLI and NBI for dilatation, tortuousness, heterogeneity, and brown spots. Detection of any one abnormal finding on NBI plus clear demarcation of the peritoneal nodules on WLI more properly diagnosed 42 peritoneal nodules of 31 patients who did not receive chemotherapy (sensitivity, 100%; specificity, 88.9%; accuracy, 95.2%). In contrast, diagnosis ability was poor for 12 peritoneal nodules of 9 patients who received chemotherapy before SL (sensitivity, 66.7%; specificity, 33.3%; accuracy, 58.3%). Conclusions: Laparoscopic NBI is a useful tool for the diagnosis of PM in advanced GC before chemotherapy, and disappearance of dilated vessels on laparoscopic NBI could be useful to evaluate the therapeutic effect.

The potential of Tenascin C in the tumor-nerve microenvironment to enhance perineural invasion and correlate with locoregional recurrence-related poor prognosis in pancreatic ductal adenocarcinoma

748

Background: Perineural invasion (PNI) is commonly seen in pancreatic ductal adenocarcinoma (PDAC) and worsens the postoperative prognosis. However, the detail mechanisms of PNI in PDAC remain unclear. Tenascin C (TNC), an extracellular matrix glycoprotein, is abundant in cancer stroma and modulates tumor progression. In this study, we hypothesized that TNC could enhance PNI in PDAC. The aim of this study was to investigate the roles of TNC in the tumor-nerve microenvironment of PDAC. Methods: We immunohistochemically examined TNC expression in 78 resected PDAC specimens. TNC staining intensity in perineural sites at the invasive front was classified as low or high, by comparison with adjacent non-cancerous tissues in the same section. The relationships between TNC expression and clinicopathological features were retrospectively analyzed. Furthermore, interactions between cancer cells and nerves after supplementation with TNC were investigated using in vitro co-culture model with a PDAC cell line and neonatal mouse dorsal root ganglion (DRG). Results: High perineural TNC expression at the invasive front, seen in 30 (38%) patients, was associated with the presence of PNI (p = 0.006), pathological T stage ≥ 3 (p = 0.01), and postoperative locoregional recurrence (p = 0.002). It was independently associated with postoperative, poor recurrence-free survival in multivariate analysis (p = 0.045). In the in vitro co-culture model, TNC supplementation significantly enhanced both neurotropism of PDAC cells and tumor tropism of a DRG. On the other hand, when PDAC cells and a DRG were cultured separately, TNC did not affect cancer cell proliferation or neural outgrowth. Furthermore, the knockdown of Annexin A2, which is known to be a receptor for TNC, cancelled the neurotropism of PDAC cell toward DRGs. Conclusions: Strong perineural TNC expression was a prognostic indicator of locoregional recurrence-related poor prognosis. The neurotropism of PDAC induced by TNC and TNC-Annexin A2 signaling pathway could be the potential therapeutic target for PDAC by regulating PNI.

P1245 Huge left atrial myxoma masks mitral regurgitation

A 61-year-old gentleman, he had shortness of breath while few weeks and getting worse, was presented to our hospital. His oxygen saturation was 94 %(O2 5L) and no crackles or rales were heard. His electrocardiogram was sinus tachycardia, and chest X-ray showed cardiomegaly and BNP level was elevated (260.3pg/mL). Transthoracic echocardiography (TTE) revealed huge mass(57 × 39mm) occupying left atrium (LA), the mass was flexible in cardiac cycle and prolapsing from LA to left ventricle, it seems like cardiac myxoma. We suspected mitral stenosis (MS) caused by the mass (peak trans mitral flow velocity 3.1m/s), mitral regurgitation(MR) was not significant, and moderate tricuspid regurgitation with pulmonary hypertension (peak systolic pressure 61 mmHg). We performed transesophageal echocardiography(TEE) and CT angiography revealed the mass at fossa ovalis, we decided surgery of removing the mass considering the risk of mitral annulus obstruction and embolism. Intraoperative findings, after taken off the mass, TEE showed moderate to severe MR not detected preoperative TEE. Additionally, it revealed the mitral annulus enlargement(42 × 38mm by 2D TEE) and may gradually induced by prolapsing the mass. Finally, surgery for mitral valve was performed and postoperative TTE showed no MR. The mass was diagnosed cardiac myxoma by pathology.

MS is relatively common in patients with prolapsing LA myxoma , and it improves after removing the mass. In this case, mitral valve was no degeneration but enlarged mitral annulus and significantly MR had revealed after removing the mass. Keep in mind that there is possibility to underestimate of MR associated with LA myxoma. To take care of mitral valve complex sufficiently in such case, and to detect these findings at preoperative echocardiography, then more useful assessment for surgery.

Abstract P1245 Figure. Huge Left Atrial Myxoma Masks MR

Nuclear Dependence of the Transverse Single-Spin Asymmetry in the Production of Charged Hadrons at Forward Rapidity in Polarized p+p, p+Al, and p+Au Collisions at sqrt[s_{NN}]=200 GeV

We report on the nuclear dependence of transverse single-spin asymmetries (TSSAs) in the production of positively charged hadrons in polarized p^{↑}+p, p^{↑}+Al, and p^{↑}+Au collisions at sqrt[s_{NN}]=200  GeV. The measurements have been performed at forward rapidity (1.4<η<2.4) over the range of transverse momentum (1.8<p_{T}<7.0  GeV/c) and Feynman x (0.1<x_{F}<0.2). We observed positive asymmetries for positively charged hadrons in p^{↑}+p collisions, and significantly reduced asymmetries in p^{↑}+A collisions. These results reveal a nuclear dependence of TSSAs for charged-hadron production in a regime where perturbative techniques are applicable. These results provide new opportunities to use p^{↑}+A collisions as a tool to investigate the rich phenomena behind TSSAs in hadronic collisions and to use TSSAs as a new handle in studying small-system collisions.

Decompressive laparotomy for abdominal compartment syndrome resulting from severe acute pancreatitis: a case report

Background

Abdominal compartment syndrome (ACS) is associated with mortality in patients with critical illness such as severe acute pancreatitis, but it remains unclear whether decompressive laparotomy for ACS can improve the prognosis of patients.

Case presentation

A woman in her 60s visited our hospital because of upper abdominal pain. On the basis of her laboratory data and abdominal contrast-enhanced computed tomography findings, acute gallstone pancreatitis was diagnosed. She underwent endoscopic sphincterotomy for the removal of the common bile duct stone. Then, a drainage tube was placed in the bile duct. However, on the 5th hospital day, her intra-abdominal pressure increased to 22 mmHg and renal dysfunction was observed, which led to the diagnosis of ACS. As intensive medical treatments did not improve her ACS, she underwent decompressive laparotomy on the 9th hospital day. Postoperatively, her laboratory data and intravesical pressure improved, and she was discharged from the hospital after abdominal closure, continuous drainage, and antibiotic therapy.

Conclusion

As the effectiveness of decompressive laparotomy for ACS has not been established, this treatment indication remains controversial. Decompressive laparotomy is considered useful for the management of ACS, if it is performed at an appropriate time, as in the present case.

[Simultaneous occurrence of an ampullary neuroendocrine tumor and multiple duodenal/jejunal gastrointestinal stromal tumors in a patient with neurofibromatosis type 1]

A 60-year-old female visited our hospital because of the identification of two duodenal tumors on upper gastrointestinal endoscopy performed for the investigation of anemia. The oral ampullary tumor was proven to be a neuroendocrine tumor (NET) on endoscopic biopsy. However, biopsy was not performed for the anal submucosal tumor (SMT) in the third duodenal portion because the tumor was included in the planned resection area. Multiple dermal soft tumors and café-au-lait spots were noted;her mother and daughter showed the same symptoms. The patient was diagnosed with neurofibromatosis type 1 (NF1). Laparotomy revealed more than 10 nodules at the serosal surface of the duodenum and proximal jejunum. Pancreaticoduodenectomy was performed with an additional 30-cm length of the jejunum that included most of the protruding tumors. Pathologically, the ampullary tumor and the other duodenal/jejunal SMTs were NET G2 and gastrointestinal stromal tumors (GISTs), respectively. Here, we report the rare case of simultaneous occurrence of an ampullary NET and multiple duodenal/jejunal GISTs in a patient with NF1.

Beam Energy and Centrality Dependence of Direct-Photon Emission from Ultrarelativistic Heavy-Ion Collisions

The PHENIX collaboration presents first measurements of low-momentum (0.4<p_{T}<3  GeV/c) direct-photon yields from Au+Au collisions at sqrt[s_{NN}]=39 and 62.4 GeV. For both beam energies the direct-photon yields are substantially enhanced with respect to expectations from prompt processes, similar to the yields observed in Au+Au collisions at sqrt[s_{NN}]=200. Analyzing the photon yield as a function of the experimental observable dN_{ch}/dη reveals that the low-momentum (>1  GeV/c) direct-photon yield dN_{γ}^{dir}/dη is a smooth function of dN_{ch}/dη and can be well described as proportional to (dN_{ch}/dη)^{α} with α≈1.25. This scaling behavior holds for a wide range of beam energies at the Relativistic Heavy Ion Collider and the Large Hadron Collider, for centrality selected samples, as well as for different A+A collision systems. At a given beam energy, the scaling also holds for high p_{T} (>5  GeV/c), but when results from different collision energies are compared, an additional sqrt[s_{NN}]-dependent multiplicative factor is needed to describe the integrated-direct-photon yield.

Abstract 4028: Tenascin C in gastric cancer stroma is a predictive marker for postoperative prognosis

Background: Tenascin C, a glycoprotein in the extracellular matrix is reportedly associated with poor clinical outcome in several malignancies. We have previously reported that tenascin C in colorectal cancer stroma is a predictive marker for liver metastasis (Br J Cancer 117:1360-70, 2017). In this study, we evaluated the clinicopathological and prognostic significance of tenascin C expression in gastric cancer stroma.

Materials and methods: Expression levels of tenascin C protein were immunohistochemically analyzed in 176 primary gastric cancer samples. Tenascin C staining intensity and relativity were classified into four scores and two groups, respectively. The correlation of the tenascin C staining intensity and relativity with clinicopathological factors, postoperative overall survival (OS) and disease-free survival (DFS) were analyzed.

Results: There were positive correlations between the tenascin C staining intensity or relativity and tumor depth, lymphatic invasion, venous invasion, lymph node metastasis, pathological stage, high preoperative carcinoembryonic antigen (CEA)&gt;5ng/ml, and high preoperative carbohydrate antigen (CA19-9) &gt;37U/ml. Multivariate analysis revealed that high tenascin C staining intensity significantly correlated with tumor invasion into the muscularis propria (p=0.015) and venous invasion (p=0.042), and that high tenascin C staining relativity correlated with venous invasion (p=0.013). Gastric cancer patients with high tenascin C staining intensity had significantly shorter postoperative OS (p&lt;0.001), whereas tenascin C staining relativity did not correlate with postoperative OS (p=0.05). High tenascin C staining intensity and relativity significantly correlated with shorter postoperative DFS (p&lt;0.001 and 0.005, respectively). Cox proportional hazard model identified high tenascin C staining intensity as an independent prognostic factor for poor postoperative OS (hazard ratio (HR): 13.16, 95% confidence interval (CI): 1.362-125.000, p=0.026) and DFS (HR: 6.02, 95%CI: 1.538-23.810, p=0.010).

Conclusions: Tenascin C protein expression in primary tumor stroma was identified as a predictive marker for postoperative prognosis in patients with gastric cancer.

Citation Format: Hirotoshi Kikuchi, Tomohiro Murakami, Sanshiro Kawata, Amane Hirotsu, Tomohiro Matsumoto, Yusuke Ozaki, Yoshihiro Hiramatsu, Kinji Kamiya, Yoshifumi Morita, Takanori Sakaguchi, Hiroyuki Konno, Hiroya Takeuchi. Tenascin C in gastric cancer stroma is a predictive marker for postoperative prognosis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 4028.

Abstract 2847: Tenascin C expression in neural microenvironment enhances perineural invasion and is associated with locoregional recurrence-related poor prognosis in pancreatic ductal adenocarcinoma

Background: Perineural invasion (PNI) is commonly seen in pancreatic ductal adenocarcinoma (PDAC) and worsens the postoperative prognosis. However, the associated mechanisms in cancer progression remain unclear. Tenascin C (TNC), an extracellular matrix glycoprotein, is abundant in cancer stroma and modulates tumor progression. The aim of this study was to evaluate the functional roles of TNC in the neural microenvironment of PDAC.

Methods: We immunohistochemically examined TNC expression in 78 resected PDAC specimens. TNC staining in perineural sites at the invasive front was classified as low or high intensity, by comparison with adjacent non-cancerous tissues in the same section. The relationships between TNC expression and clinicopathological features were retrospectively analyzed. Furthermore, interactions between cancer cells and nerves after supplementation with TNC were investigated when co-culturing a PDAC cell line with a mouse dorsal root ganglion (DRG) in vitro.

Results: High perineural TNC expression at the invasive front, seen in 30 (38%) patients, was associated with PNI (p = 0.006), pathological T stage ≥ 3 (p = 0.01), and postoperative locoregional recurrence (p = 0.002). It was independently associated with postoperative, poor recurrence-free survival in multivariate analysis (p = 0.045). In the in vitro co-culture model, supplementation with TNC significantly enhanced both neurotropism of PDAC cells and tumor tropism of a DRG. On the other hand, when PDAC cells and a DRG were cultured separately, TNC did not affect cancer cell proliferation or neural outgrowth.

Conclusions: Strong perineural TNC expression was a prognostic indicator of locoregional recurrence-related poor prognosis. The neurotropism of PDAC induced by TNC suggests that TNC could serve as a therapeutic target for PDAC.

Citation Format: Satoru Furuhashi, Takanori Sakaguchi, Tomohiro Murakami, Mayu Fukushima, Yoshifumi Morita, Koji Ikegami, Hirotoshi Kikuchi, Megumi Baba, Mitsutoshi Setou, Hiyoya Takeuchi. Tenascin C expression in neural microenvironment enhances perineural invasion and is associated with locoregional recurrence-related poor prognosis in pancreatic ductal adenocarcinoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 2847.

Body weight loss after surgery affects the continuity of adjuvant chemotherapy for pancreatic cancer

BACKGROUND

Postoperative chemotherapy is beneficial for many pancreatic cancer patients. However, some patients require dose reduction or the discontinuation of adjuvant chemotherapy because of adverse treatment-related effects. In this study, we aimed to evaluate two main outcomes. First, we evaluated the clinicopathological factors affecting patient disease-free survival (DFS) and overall survival (OS) following upfront surgery. Second, we evaluated the factors that influence the continuity of adjuvant chemotherapy.

METHODS

Fifty-four patients with resected pancreatic cancer were enrolled. First, we evaluated the clinicopathological factors affecting postoperative survival using the Kaplan-Meier method and Cox regression method. Next, factors affecting the continuity of adjuvant chemotherapy were analyzed using multiple logistic regression analysis.

RESULTS

Univariate and multivariate analyses revealed that positive LN metastasis (HR (95% CI) 6.329 (2.381-16.95); p < 0.001) and relative dose intensity (RDI) < 80% for adjuvant chemotherapy (HR (95% CI) 5.154 (1.761-15.15); p = 0.003) were independent predictive factors for DFS. Regarding OS, extended dissection of the nerve plexus around the superior mesenteric artery (SMA) (HR (95% CI) 4.504 (1.721-11.76); p = 0.002), positive microscopic surgical margin (HR (95% CI) 5.565 (1.724-17.96); p = 0.004), and adjuvant chemotherapy of RDI < 80% (HR (95% CI) 3.534 (1.135-2.667); p = 0.029) were also independent predictive factors. Moreover, the level of RDI significantly correlated with DFS and OS. Multiple logistic regression analysis revealed that low RDI was significantly associated with postoperative body weight loss (BWL) ≥ 10%.

CONCLUSIONS

The following factors were significantly associated with poor survival: extended dissection of the nerve plexus around the SMA, lymph node metastasis, residual tumor, and RDI of the adjuvant chemotherapy. Patient's prognosis with adjuvant chemotherapy of RDI < 80% was worse. BWL ≥10% was the most important factor affecting the continuity of adjuvant chemotherapy. Perioperative nutritional intervention is necessary for patients who receive adjuvant chemotherapy for advanced pancreatic cancer.

Detection of Talaromyces macrosporus and Talaromyces trachyspermus by a PCR assay targeting the hydrophobin gene

Talaromyces species are typical fungi capable of producing the heat-resistant ascospores responsible for the spoilage of processed food products. Hydrophobins, which are unique to fungi, are small secreted proteins that form amphipathic layers on the outer surface of fungal cell walls. In this study, species-specific primer sets for detecting and identifying Talaromyces macrosporus and Talaromyces trachyspermus were designed based on hydrophobin gene sequences. A conventional polymerase chain reaction (PCR) assay using these primer sets produced species-specific amplicons for T. macrosporus and T. trachyspermus. The detection limit for each primer set was 100 pg template DNA. This assay also detected fungal DNA extracted from blueberries inoculated with T. macrosporus. Other heat-resistant fungi, including Byssochlamys, Neosartorya and Talaromyces species, which cause food spoilage, were not detected in PCR amplifications with these primer sets. Furthermore, a conventional PCR assay using a crude DNA extract as the template also yielded amplicons specific to T. macrosporus and T. trachyspermus. The simple and rapid PCR assay described herein is highly species-specific and can reliably detect T. macrosporus and T. trachyspermus, suggesting it may be relevant for the food and beverage industry. SIGNIFICANCE AND IMPACT OF THE STUDY: The heat-resistant ascospores of Talaromyces macrosporus and Talaromyces trachyspermus are responsible for food spoilage after pasteurization. Traditional methods for detecting fungal contamination based on morphological characteristics are time-consuming and exhibit low sensitivity and specificity. In this study, a conventional polymerase chain reaction (PCR) assay based on hydrophobin gene sequences was developed for the specific detection of T. macrosporus and T. trachyspermus. This detection method was simple, rapid and highly specific. These results suggest that the conventional PCR assay developed in this study may be useful for detecting T. macrosporus and T. trachyspermus in raw materials and processed food products.

Pseudorapidity Dependence of Particle Production and Elliptic Flow in Asymmetric Nuclear Collisions of p+Al, p+Au, d+Au, and ^{3}He+Au at sqrt[s_{NN}]=200 GeV

Asymmetric nuclear collisions of p+Al, p+Au, d+Au, and ^{3}He+Au at sqrt[s_{NN}]=200  GeV provide an excellent laboratory for understanding particle production, as well as exploring interactions among these particles after their initial creation in the collision. We present measurements of charged hadron production dN_{ch}/dη in all such collision systems over a broad pseudorapidity range and as a function of collision multiplicity. A simple wounded quark model is remarkably successful at describing the full data set. We also measure the elliptic flow v_{2} over a similarly broad pseudorapidity range. These measurements provide key constraints on models of particle emission and their translation into flow.

Lethal Bleeding from a Duodenal Cancerous Ulcer Communicating with the Superior Mesenteric Artery in a Patient with Pancreatic Head Cancer

Pancreatic cancer often invades the duodenum and causes obstruction, but rarely causes massive duodenal bleeding. A 68-year-old male was admitted to our hospital because of vomiting. Enhanced abdominal CT showed a hypovascular tumor with air bubbles in the uncinate process of the pancreas. The tumor invaded the duodenum and metastasized to the liver and peritoneum. The main trunk of the superior mesenteric artery (SMA) was circumferentially involved. After admission, he had hematemesis and melena. Emergency gastroduodenoscopy revealed pulsating vessels in the third portion of the duodenum and he eventually experienced hemorrhagic shock. Severe bleeding occurred from his mouth and anus like a catastrophic flood. It was difficult to sustain blood pressure even with massive blood transfusion with pumping. After insertion of an intra-aortic balloon occlusion catheter, the massive bleeding was eventually stopped. Although we attempted interventional radiography, aortography revealed direct communication between the main SMA trunk and the duodenal lumen. The tumor was considered anatomically and oncologically unresectable. Thus, we did not perform further intervention. The patient died 2 h after angiography. Herein, we report the case of pancreatic head cancer causing lethal bleeding associated with tumor-involved SMA. Duodenal bleeding associated with pancreatic cancer invasion should be considered as an oncogenic emergency.

Role of caveolin-1 in hepatocellular carcinoma arising from non-alcoholic fatty liver disease

The molecular features of hepatocellular carcinoma arising from non-alcoholic fatty liver disease (NAFLD-HCC) are not well known. In this study, we investigated the mechanism by which NAFLD-HCC survives in a fat-rich environment. We found that caveolin (CAV)-1 was overexpressed in clinical specimens from NAFLD-HCC patients. HepG2, HLE, and HuH-7 HCC cell lines showed decreased proliferation in the presence of the saturated fatty acids palmitic acid and stearic acid, although only HLE cells expressed high levels of CAV-1. HLE cells treated with oleic acid (OA) showed robust proliferation, whereas CAV-null HepG2 cells showed reduced proliferation and increased apoptosis. CAV-1 knockdown in HLE cells attenuated the OA-induced increase in proliferation and enhanced apoptosis. Liquid chromatography-tandem mass spectrometry analysis revealed that the levels of OA-containing ceramide, a pro-apoptotic factor, were higher in HepG2 and CAV-1-deficient HLE cells than in HLE cells, suggesting that CAV-1 inhibits apoptosis by decreasing the level of OA-containing ceramide. These results indicate that CAV-1 is important for NAFLD-HCC survival in fatty acid-rich environments and is a potential therapeutic target.

Abstract 2588: Label-free classification of live cells using quantitative phase microscopy images for negative selection of circulating tumor cells

Background: Circulating tumor cells (CTCs) are used as a liquid biopsy target in the treatment of cancer patients and are important for personalized medicine. Most CTC detection technologies are based on their surface markers such as EpCAM and cytokeratin. However, those positive selection methodologies appear to count only some CTCs because invasive tumor cells tend to change their surface markers during progression. Because the vast majority of nucleated cells circulating in the bloodstream are white blood cells (WBCs), eliminating WBCs from circulation is an efficient method to purify CTCs by negative selection. In this study, we demonstrate the development of cell recognition by computer vision technologies for pattern recognition based on the morphological features of live cells.

Materials and methods: Blood samples were obtained from healthy volunteers. Five cancer cell lines, SW480, DLD-1, HCT116, Panc-1, and HepG2 were used as CTC models. We applied quantitative phase microscopy (QPM) that detects the small delay of the phase and image optical path lengths and provides quantitative morphological information of live cells with high contrast without staining. WBC recognition algorithm was developed using computer vision technologies for pattern recognition based on the histogram-oriented gradient (HOG) features extracted from QPM images (QPIs) for negative selection of CTCs.

Results: We observed WBCs and five cell line cells by QPM, extracted certain features from the obtained images as training data for pattern recognition, and created an algorithm to differentiate WBCs from cell lines. The obtained algorithm successfully differentiated WBCs from cell lines (AUC=0.98). To simulate WBCs and cell lines with a small and strong change, respectively, in optical thickness (OT) at the center of the cell, we created a homogeneous hemi-ellipsoid model and a heterogeneous hemi-ellipsoid model, respectively. In these models, OT gradually increased from the edge to the center, but fluctuated around the center to simulate intracellular heterogeneity of a cancer cell. Based on these simulations, the classifier was interpreted to recognize intracellular heterogeneity, especially in the center of the cell. Finally, we applied our image recognition methods to QPIs of the cells flowing in the chamber, and properly differentiate WBCs from cell line cells flowing in the chamber (AUC=0.99).

Conclusions: We developed a novel method for label-free image identification of live cells by computer vision technologies for pattern recognition based on the features of QPIs. Our study makes it possible to sort CTCs in a non-cytotoxic manner, thus providing good opportunities for molecular biological approaches to isolate CTCs.

Citation Format: Hirotoshi Kikuchi, Yusuke Ozaki, Amane Hirotsu, Hidenao Yamada, Shigetoshi Okazaki, Tomohiro Murakami, Tomohiro Matsumoto, Yoshihiro Hiramatsu, Kinji Kamiya, Takanori Sakaguchi, Hiroyuki Konno, Hiroya Takeuchi. Label-free classification of live cells using quantitative phase microscopy images for negative selection of circulating tumor cells [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 2588.

Abstract 1067: Tenascin C in colorectal cancer stroma is a predictive marker for liver metastasis and is a potent target of miR-198 as identified by microRNA analysis

Background: Liver metastasis in colorectal cancer (CRC) is still one of the major determinants of survival. Tumor stroma has important roles in the development of colorectal cancer (CRC) metastasis. MicroRNAs (miRNAs) are known to regulate the expression of genes involved in many physiological conditions, including cancer. Previous studies reported important roles of miRNAs in cancer cells in CRC development and metastasis. However, only few studies have focused on miRNA expression in CRC stroma. In this study, we revealed the miRNA expression profiles in tumor stroma by miRNA array analysis using Laser captured microdissection (LCM) to identify miRNAs and their target genes as novel molecular markers involved in CRC liver metastasis.

Methods: Tumor stroma was isolated from formalin-fixed, paraffin-embedded tissues of primary CRCs with or without liver metastasis by LCM, and miRNA expression was analyzed using TaqMan miRNA arrays.

Results: Hierarchical clustering classified 16 CRCs into two groups according to the existence of synchronous liver metastasis. Combinatory target prediction identified tenascin C (TNC) as a predicted target of miR-198, one of the top 10 miRNAs downregulated in tumor stroma of CRCs with synchronous liver metastasis. Immunohistochemical analysis of TNC in 139 primary CRCs revealed that a high staining intensity was correlated with synchronous liver metastasis (P&lt;0.001). TNC staining intensities in the tumor stroma of 83 CRC liver metastases revealed a higher staining in liver metastases than in primary CRCs independently of preoperative chemotherapy. Univariate and multivariate analyses revealed that the TNC staining intensity was an independent prognostic factor to predict postoperative overall survival (P=0.005; n=139) and liver metastasis-free survival (P=0.001; n=128). To evaluate the biological link between miR-198 and TNC, we first checked expression levels of miR-198 in the 16 samples in miRNA array data, and compared them with TNC staining intensities. The CRC samples expressing miR-198 tended to have lower levels of TNC expression in comparison with those without miR-198 expression, although the difference was not statistically significant (P=0.237). Next, we transfected a miR-198 mimic or a miR-198 inhibitor into SW620 human colon cancer cells and CCD-18Co human colon fibroblast cells and analyzed the expression change of TNC protein by western blotting. The relative protein expression of TNC was suppressed by treatment with the miR-198 mimic and increased by miR-198 inhibitor.

Conclusions: Alterations of miRNAs in CRC stroma appear to form a metastasis-permissive environment that can elevate TNC to promote liver metastasis. TNC in primary CRC stroma has the potential to be a novel biomarker to predict postoperative prognosis.

Citation Format: Tomohiro Murakami, Hirotoshi Kikuchi, Hisahito Ishimatsu, Sanshiro Kawata, Amane Hirotsu, Tomohiro Matsumoto, Yusuke Ozaki, Yoshihiro Hiramatsu, Kinji Kamiya, Megumi Baba, Satoshi Baba, Masatoshi Kitagawa, Takanori Sakaguchi, Hiroyuki Konno, Hiroya Takeuchi. Tenascin C in colorectal cancer stroma is a predictive marker for liver metastasis and is a potent target of miR-198 as identified by microRNA analysis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 1067.

Stearate-to-palmitate ratio modulates endoplasmic reticulum stress and cell apoptosis in non-B non-C hepatoma cells

The increased prevalence of hepatocellular carcinoma (HCC) without viral infection, namely, NHCC, is a major public health issue worldwide. NHCC is frequently derived from non‐alcoholic fatty liver (NAFL) and non‐alcoholic steatohepatitis, which exhibit dysregulated fatty acid (FA) metabolism. This raises the possibility that NHCC evolves intracellular machineries to adapt to dysregulated FA metabolism. We herein aim to identify NHCC‐specifically altered FA and key molecules to achieve the adaptation. To analyze FA, imaging mass spectrometry (IMS) was performed on 15 HCC specimens. The composition of saturated FA (SFA) in NHCC was altered from that in typical HCC. The stearate‐to‐palmitate ratio (SPR) was significantly increased in NHCC. Associated with the SPR increase, the ELOVL6 protein level was upregulated in NHCC. The knockdown of ELOVL6 reduced SPR, and enhanced endoplasmic reticulum stress, inducing apoptosis of Huh7 and HepG2 cells. In conclusion, NHCC appears to adapt to an FA‐rich environment by modulating SPR through ELOVL6.

Surgery for metastatic gastrointestinal stromal tumor: to whom and how to?

Although imatinib is a standard treatment for metastatic or recurrent gastrointestinal stromal tumors (GISTs), acquired c-kit mutations reportedly cause secondary resistance to imatinib. Sunitinib is a tyrosine kinase inhibitor (TKI) that can be used as second-line therapy in imatinib-resistant or -intolerant GISTs. For sunitinib-resistant or -intolerant GISTs, regorafenib is a standard third-line treatment. Although TKI therapies have revolutionized the treatment of recurrent or metastatic GISTs, they cannot cure GISTs. Therefore, in the era of TKIs, role of cytoreductive surgery for recurrent or metastatic GISTs has been discussed. Retrospective studies of treatment strategies with front-line surgery prior to imatinib have shown that initial cytoreduction confers no benefit in cases of advanced or recurrent GIST, and administering imatinib is the principle treatment. Most retrospective studies report cytoreductive surgery to be feasible in patients with metastatic GIST whose disease is stable or responsive to imatinib. Cytoreductive surgery may be indicated in limited disease progression refractory to imatinib when complete resection is possible, but case selection is critical. Cytoreductive surgery for metastatic GIST treated with sunitinib seems less feasible because of high rates of incomplete resections and complications. The role of cytoreductive surgery for metastatic GISTs would be difficult to establish in a prospective study; individualized treatments need to be carefully designed based on c-kit and platelet-derived growth factor receptor alpha (PDGFRA) mutations and other factors.

Comprehensive evaluation of liver resection procedures: surgical mind development through cognitive task analysis

Background

Liver resection is a complex procedure for trainee surgeons. Cognitive task analysis (CTA) facilitates understanding and decomposing tasks that require a great proportion of mental activity from experts.

Methods

Using CTA and video-based coaching to compare liver resection by open and laparoscopic approaches, we decomposed the task of liver resection into exposure (visual field building), adequate tension made at the working plane (which may change three-dimensionally during the resection process), and target processing (intervention strategy) that can bridge the gap from the basic surgical principle.

Results

The key steps of highly-specialized techniques, including hanging maneuvers and looping of extra-hepatic hepatic veins, were shown on video by open and laparoscopic approaches.

Conclusions

Familiarization with laparoscopic anatomical orientation may help surgeons already skilled at open liver resection transit to perform laparoscopic liver resection smoothly. Facilities at hand (such as patient tolerability, advanced instruments, and trained teams of personnel) can influence surgical decision making. Application of the rationale and realizing the interplay between the surgical principles and the other paramedical factors may help surgeons in training to understand the mental abstractions of experienced surgeons, to choose the most appropriate surgical strategy effectively at will, and to minimize the gap.

Measurements of Multiparticle Correlations in d+Au Collisions at 200, 62.4, 39, and 19.6 GeV and p+Au Collisions at 200 GeV and Implications for Collective Behavior

Recently, multiparticle-correlation measurements of relativistic p/d/^{3}He+Au, p+Pb, and even p+p collisions show surprising collective signatures. Here, we present beam-energy-scan measurements of two-, four-, and six-particle angular correlations in d+Au collisions at sqrt[s_{NN}]=200, 62.4, 39, and 19.6 GeV. We also present measurements of two- and four-particle angular correlations in p+Au collisions at sqrt[s_{NN}]=200  GeV. We find the four-particle cumulant to be real valued for d+Au collisions at all four energies. We also find that the four-particle cumulant in p+Au has the opposite sign as that in d+Au. Further, we find that the six-particle cumulant agrees with the four-particle cumulant in d+Au collisions at 200 GeV, indicating that nonflow effects are subdominant. These observations provide strong evidence that the correlations originate from the initial geometric configuration, which is then translated into the momentum distribution for all particles, commonly referred to as collectivity.

Nuclear Dependence of the Transverse-Single-Spin Asymmetry for Forward Neutron Production in Polarized p+A Collisions at sqrt[s_{NN}]=200 GeV

During 2015, the Relativistic Heavy Ion Collider (RHIC) provided collisions of transversely polarized protons with Au and Al nuclei for the first time, enabling the exploration of transverse-single-spin asymmetries with heavy nuclei. Large single-spin asymmetries in very forward neutron production have been previously observed in transversely polarized p+p collisions at RHIC, and the existing theoretical framework that was successful in describing the single-spin asymmetry in p+p collisions predicts only a moderate atomic-mass-number (A) dependence. In contrast, the asymmetries observed at RHIC in p+A collisions showed a surprisingly strong A dependence in inclusive forward neutron production. The observed asymmetry in p+Al collisions is much smaller, while the asymmetry in p+Au collisions is a factor of 3 larger in absolute value and of opposite sign. The interplay of different neutron production mechanisms is discussed as a possible explanation of the observed A dependence.

Design of a species-specific PCR method for the detection of the heat-resistant fungi Talaromyces macrosporus and Talaromyces trachyspermus

Heat-resistant fungi occur sporadically and are a continuing problem for the food and beverage industry. The genus Talaromyces, as a typical fungus, is capable of producing the heat-resistant ascospores responsible for the spoilage of processed food products. Isocitrate lyase, a signature enzyme of the glyoxylate cycle, is required for the metabolism of non-fermentable carbon compounds, like acetate and ethanol. Here, species-specific primer sets for detection and identification of DNA derived from Talaromyces macrosporus and Talaromyces trachyspermus were designed based on the nucleotide sequences of their isocitrate lyase genes. Polymerase chain reaction (PCR) using a species-specific primer set amplified products specific to T. macrosporus and T. trachyspermus. Other fungal species, such as Byssochlamys fulva and Hamigera striata, which cause food spoilage, were not detected using the Talaromyces-specific primer sets. The detection limit for each species-specific primer set was determined as being 50 pg of template DNA, without using a nested PCR method. The specificity of each species-specific primer set was maintained in the presence of 1,000-fold amounts of genomic DNA from other fungi. The method also detected fungal DNA extracted from blueberry inoculated with T. macrosporus. This PCR method provides a quick, simple, powerful and reliable way to detect T. macrosporus and T. trachyspermus.

SIGNIFICANCE AND IMPACT OF THE STUDY

Polymerase chain reaction (PCR)-based detection is rapid, convenient and sensitive compared with traditional methods of detecting heat-resistant fungi. In this study, a PCR-based method was developed for the detection and identification of amplification products from Talaromyces macrosporus and Talaromyces trachyspermus using primer sets that target the isocitrate lyase gene. This method could be used for the on-site detection of T. macrosporus and T. trachyspermus in the near future, and will be helpful in the safety control of raw materials and in food and beverage production.

[Spontaneous regression of pancreatic arteriovenous malformation under the influence of severe acute pancreatitis: a case report]

A 49-year-old man was diagnosed with severe acute pancreatitis because of pancreatic arteriovenous malformation (AVM). The pancreatic AVM spontaneously regressed during conservative treatment for severe acute pancreatitis. Transarterial embolization of an aneurysm in an artery branch flowing into the pancreatic AVM was performed using metallic coils, following amelioration of severe acute pancreatitis. The complete elimination of the pancreatic AVM was confirmed 1 year after embolization, and the patient has had no recurrence of pancreatic AVM and pancreatitis for over 6 years. Most cases of pancreatic AVMs with acute pancreatitis require surgical resection. This is a rare case in which the pancreatic AVM spontaneously regressed under the influence of acute severe pancreatitis.

Abstract 1862: Direct observation of colorectal cancers using field-emission scanning electron microscopy with a thin polymer membrane, the NanoSuit

Background: Field-emission scanning electron microscopy (FE-SEM) enables us to observe nano-sized objects with great depth of focus and high resolution. However, the observation of biological samples including colorectal tissues using an FE-SEM has been difficult because it requires to evacuate its inside to prevent electron scattering, therefore all organisms containing ca. 70% water are rapidly evaporated and consequently caused structural disruption and collapse. To overcome the limitations of the conventional SEM, equipment such as low-vacuum scanning electron microscopy and environmental scanning electron microscope was developed. However, they are not reliable enough to investigate living organisms or wet tissues with high resolution level. We have recently reported that a simple surface modification consisting of a thin extra layer, coined the term ‘NanoSuit®’, can keep organisms alive in the high vacuum (10−3 to 10−7 Pa) of the SEM. We now modified the technique and developed a new solution, which enables FE-SEM observations of wet tissues. In this study, we utilized this technique to observe real images of colorectal cancers and their adjacent normal mucosae at high resolution.

Materials and methods: Colorectal cancer tissues and their adjacent normal mucosa were cut with a scalpel from specimens surgically resected. All patients enrolled in this study provided written informed consent. Observations were carried out with an FE-SEM (S-4800, Hitachi or JEM-7100F, JEOL, Japan) at acceleration voltage of 1.0 kV. The vacuum level of the observation chamber was 10-3 - 10-7 Pa. The newly developed surface shield enhancer (SSE) solution was used to make NanoSuit® for wet tissue observation. To form the NanoSuit®, the specimens were dipped for 1 min into the SSE solution and blotted briefly thereafter put on dry filter paper to remove excess solution. Specimens were then introduced directly into an FE-SEM to form a NanoSuit® following irradiation of the electron beam.

Results: Fine structures of intestinal crypt and villi were observed in normal colon mucosa using FE-SEM with a NanoSuit®, whereas fixed specimens prepared with conventional method showed obvious structural damage. Comparing with the region of normal colon mucosa, colorectal cancer lesion had relatively amorphous surface, therefore the border between non-cancerous mucosa and cancer lesions in colon tissues are able to be distinguished under high magnification. In addition, fiber-like structure was observed at the border between noncancerous mucosa and cancer lesions, suggesting an invasive front of colorectal cancer.

Conclusions: We successfully observed the real mucosal surfaces and cancer lesions of colorectum with high resolution by an FE-SEM using a newly developed vacuum-proof suit, the “NanoSuit®”. This novel technique will enable us to investigate further physiopathology of GI tract including cancers.

Citation Format: Hirotoshi Kikuchi, Tomohiro Matsumoto, Takanori Hiraide, Yusuke Ozaki, Amane Hirotsu, Tomohiro Murakami, Toshiki Kawabata, Yoshihiro Hiramatsu, Kinji Kamiya, Takanori Sakaguchi, Yasuharu Takaku, Isao Ohta, Takahiro Hariyama, Hiroyuki Konno. Direct observation of colorectal cancers using field-emission scanning electron microscopy with a thin polymer membrane, the NanoSuit [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 1862. doi:10.1158/1538-7445.AM2017-1862

Abstract 2048: Saturated fatty acids in cell membrane phospholipids play an important role in chemoresistance in colorectal cancer

[Background and Aim] Resistance to chemotherapy represents the major obstacle to survival in patients with chemoresistant colorectal cancer. Various factors, such as drug efflux, autocrine survival signaling, and alterations in DNA damage repair mechanisms, can contribute to chemoresistance; however, the actual underlying mechanism is yet to be elucidated. The aim of this study was to elucidate the mechanism behind anticancer drug resistance based on lipidomics.

[Materials and Methods] 1) Spheroids were derived from three colorectal cancer patient-derived xenograft models (A, B, and C) that were incubated with chemotherapeutic agents, such as 5-fluorouracil (5-FU). We analyzed the response rate of spheroids under 5-FU treatment. Global lipid analysis was performed on 5-FU resistance spheroids (A) and sensitive spheroids (C) using a Q Exactive LC-MS/MS mass spectrometer, and lipid identification was performed using the Lipid Search software. 2) We tried to identify genes that were responsible for changes in phospholipid profiles in the cell membrane. 3) To determine phospholipid profile changes in the cell membrane that occur in colon cancer cell lines (HCT116, SW480) during anticancer drug resistance, the genes responsible for such resistance were knocked down using siRNA.

[Results and discussion] 1) Response to 5-FU was different in individual spheroids. Global lipid analysis and chemosensitivity assay revealed that phospholipids of 5-FU resistant spheroids were rich in saturated fatty acids (SFAs), while those of the 5-FU sensitive spheroids were rich in monounsaturated fatty acids (MUFAs). 2) The enzyme stearoyl-CoA desaturase (SCD) converts SFAs to MUFAs in the phospholipids. Based on these findings we hypothesized that decreased SCD expression is possibly associated with chemoresistance. 3) Cell lines with SCD knock down demonstrated increased SFA containing phospholipids and chemoresistance towards 5-FU. Viable cells after the administration of the anti-cancer agent confirmed that the expression of CD44 was upregulated. Therefore, changes in the phospholipid composition of cell membranes regulate 5-FU resistance in colon cancer.

[Conclusions] Identification and analysis of the role of membrane lipids has become possible using high-sensitivity and high-resolution mass spectrometers and the relevant software, such as Lipid Search. Changes of phospholipid composition regulates chemoresistance. In future, investigation of the pathophysiology of membrane lipids in cancer may help to reveal novel strategies for cancer therapy.

Citation Format: Takanori Hiraide, Takanori Sakaguchi, Satoru Furuhashi, Tomohiro Matsumoto, Yusuke Ozaki, Ryota Kiuchi, Makoto Takeda, Yasushi Shibasaki, Yoshifumi Morita, Hirotoshi Kikuchi, Megumi Baba, Mitsutoshi Setou, Hiroyuki Konno. Saturated fatty acids in cell membrane phospholipids play an important role in chemoresistance in colorectal cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 2048. doi:10.1158/1538-7445.AM2017-2048

Abstract 4438: MiRNA expression analysis in the tumor stroma predicts Tenascin C to promote colorectal cancer liver metastasis

Background: Liver is the most common site for colorectal cancer (CRC) metastasis, and mechanisms underlying colorectal liver metastasis need to be explored. The tumor microenvironment consists of many stromal cells which are known to interact with cancer cells and to promote metastasis. Recently many microRNAs (miRNAs) specifically expressed in the stroma is receiving attention. In this study, we analyzed the differences in miRNA expression profiles between peritumoral stroma of CRCs with and without liver metastasis, and sought to identify liver metastasis-promoting molecules that can be regulated by the altered expression of miRNAs in the peritumoral stroma.

Materials and methods: The formalin-fixed paraffin-embedded (FFPE) specimens of primary CRCs from 8 patients without metastasis, 4 patients with synchronous liver metastasis and 4 patients with metachronous liver metastasis were used for miRNA array analysis. None of the patients had received any treatment prior to surgery. Tumor stroma was isolated from FFPE samples using laser capture microdissection without contamination of cancer cells, and total RNAs were extracted. The quality of total RNA was assessed, and miRNA expression was analyzed using TaqMan miRNA arrays. Protein expression of Tenascin C (TNC) was immunohistochemically analyzed in 139 primary CRCs.

Results: Unsupervised hierarchical clustering classified 16 samples analyzed into two groups according to their miRNA expressions. CRCs with synchronous liver metastasis showed differential miRNA expression profiles from those without liver metastasis or with metachronous liver metastasis. Top10 miRNAs up-regulated in CRCs with synchronous liver metastasis vs. CRCs without liver metastasis or with metachronous liver metastasis were hsa-miR-518b, 618, 186, 520f, 29c, 520e, 155, 30c, 518e and 106b, and those down-regulated in CRCs with synchronous liver metastasis were hsa-miR-302a, 551b, 627, 628-5p, 19a, 372, 302b, 384, 198 and 636. The predictive targets of the top 10 down-regulated miRNAs were analyzed in silico using on-line data base such as .miRDB. TNC was identified as a candidate for metastasis-promoting molecule which can be upregulated in the peritumoral stroma followed by the downregulation of miRNAs. Immunohistochemical analysis revealed that protein expression of TNC was higher in the stroma of primary CRCs with synchronous liver metastasis compared with those without liver metastasis or with metachronous liver metastasis. Furthermore, high expression of TNC protein in the primary CRC stroma was correlated with shorter overall survival and liver metastasis-free survival.

Conclusions: Alterations of miRNAs in the CRC stroma appear to create a metastasis permissive environment in which TNC plays an important role. Expression of TNC in primary CRC stroma has the potential to be a novel biomarker to predict the risk of postoperative liver metastasis in CRC patients.

Citation Format: Tomohiro Murakami, Hisahito Ishimatsu, Hirotoshi Kikuchi, Amane Hirotsu, Tomohiro Matsumoto, Yusuke Ozaki, Toshiki Kawabata, Yoshihiro Hiramatsu, Kinji Kamiya, Megumi Baba, Takanori Sakaguchi, Hiroyuki Konno. MiRNA expression analysis in the tumor stroma predicts Tenascin C to promote colorectal cancer liver metastasis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 4438. doi:10.1158/1538-7445.AM2017-4438

Duodenal adenocarcinoma successfully diagnosed with transabdominal ultrasonography

Adenocarcinoma arising from the duodenum is relatively rare. Diagnosis of this disease at an early stage is difficult because its symptoms are usually nonspecific. We herein present a case in which duodenal adenocarcinoma was successfully found by transabdominal ultrasonography. Under ultrasonography, the tumor was located in the proximal duodenum apart from the papilla of Vater, and the serosa was intact. Other diagnostic modalities showed no evidence of adjacent organ invasion or distant metastasis. Therefore, pancreatoduodenectomy was performed and the postoperative course was uneventful. The ultrasonographic findings corresponded well with the pathological diagnosis. The following three procedures were essential in this case: systematic scanning of the digestive tract to determine the location of the lesion, graded compression ultrasound to remove air bubbles from the region of interest, and precise observation of the intestinal walls using proper transducers. The precise and skillful performance of transabdominal ultrasonography using a suitable device can help to diagnose duodenal adenocarcinoma, a rare malignancy.