Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

[Preoperative Esophageal Decompression and Enteral Nutrition Using a W-ED Tube in Patients with Esophagogastric Junction Cancer-A Case Report]

The patient was a 67-year-old male diagnosed with adenocarcinoma of the esophagogastric junction. The esophagus was markedly dilated due to severe stenosis, and aspiration pneumonia was observed. Therefore, he was treated with a W- ED tube for simultaneous esophageal decompression and enteral nutrition. Two weeks of W-ED tube placement improved esophageal dilatation and pneumonia while maintaining nutritional status; thus, he underwent proximal gastrectomy, lower esophagectomy and combined resection of distal pancreas, spleen and left crus of diaphragm with jejunal interposition reconstruction. His postoperative course was uneventful, and he was discharged 16 days after surgery without any postoperative infectious complications such as pneumonia, anastomotic leakage, pancreatic fistula and enterocolitis. In the preoperative management for patients with esophagogastric junction cancer with severe stenosis, simultaneous esophageal decompression and enteral nutrition using a W-ED tube is very useful because it can improve aspiration pneumonia, reduce the risk of anastomotic leakage by improving esophageal edema, and prevent disuse atrophy of small intestinal villi.

[A Case of Gastric Carcinoma with Lymphoid Stroma That Was Difficult to Diagnose Preoperatively]

A 71-year-old man was referred to our hospital because of a gastric submucosal tumor. Gastrointestinal stromal tumor (GIST)was diagnosed in the antrum of the stomach and local resection was undergone. At this time, upper gastrointestinal endoscopy found the gastric submucosal tumor with a size of about 5 mm on the posterior wall of the fundus, but it was followed up. The lesion had grown to a size of about 10 mm by endoscopy 2 years later, and a biopsy was performed. Gastric mucosa associated lymphoid tissue(MALT)lymphoma was diagnosed by pathological examination, and Helicobacter pylori eradication therapy was performed. Endoscopy after treatment further increased the size of the lesion to about 20 mm, and ulceration was also observed. A biopsy was performed again, and a diagnosis of poorly differentiated adenocarcinoma was made, and laparoscopic proximal gastrectomy was undergone. It was the diagnosis of gastric carcinoma with lymphoid stroma(GCLS), pT3N0M0, pStage ⅡA in the postoperative pathological examination. GCLS is a rare disease with a frequency of about 1 to 4% of all gastric cancers, and preoperative diagnosis is difficult. From the morphology and histology, the differential diagnosis from submucosal tumors and lymphomas becomes problems.

[A Case of Gastric Cancer with Extensive Lymph Node Metastasis Causing Stenosis Symptoms in the Primary pCR after Preoperative Chemotherapy]

A 65‒year‒old man was found with a circumferential type 2 tumor in the gastric antrum by upper gastrointestinal endoscopy, and biopsy revealed poorly a differentiated adenocarcinoma and HER2‒negative results. According to imaging examinations and laparoscopy, he was diagnosed with an advanced gastric cancer, classified as cT4a(SE)N3M0 and cStage Ⅲ. He underwent neoadjuvant chemotherapy(SOX regimen)because of the bulky N finding. After 2 courses of the treatment, marked reductions in the primary gastric lesion and metastatic lymph nodes were observed, although stenosis appeared at the gastric tumor site. The W‒ED tube was used to depressurize the stomach and to manage his nutrition, and the patient's surgery was conducted under good general conditions. We performed a distal gastrectomy(D2 dissection)and cholecystectomy. Histopathological examination showed no viable tumor cells in the primary gastric lesion(Grade 3). Two metastases were found in the dissected lymph nodes, although only a few cancer cells persisted. We report a case of gastric cancer in which pCR was obtained in the primary lesion, although stenosis appeared after the neoadjuvant chemotherapy.

The therapeutic strategy for advanced gastric cancer with pyloric stenosis and liver metastasis; successfully treated by gastro-jejunal bypass and chemotherapy first, followed by curative R0 resection

Background

The indication of surgical resection for liver metastasis from gastric cancer (GC) is still limited and controversial because of its more aggressive oncological characteristics than liver metastasis from colorectal cancer. Pyloric stenosis causes an inadequate oral intake and malnutrition in GC patients. We herein report a case of GC with these two factors that was successfully treated by the combination of gastro-jejunal bypass and chemotherapy, followed by curative R0 resection.

Case presentation

A 60-year-old man was diagnosed with type 2 GC with liver metastasis and pyloric stenosis, which was confirmed as the HER2-positive type. He underwent gastrojejunostomy and received capecitabine and cisplatin (XP) + trastuzumab chemotherapy. After three courses of the XP + trastuzumab regimen, shrinkage of the primary lesion and liver metastasis was confirmed and his nutritional parameters markedly improved with a stable oral intake after bypass surgery. He underwent curative R0 resection by distal gastrectomy with D2 lymphadenectomy and partial hepatectomy. Histologically, viable tumor cells were observed in less than one-third of the primary lesion, and only scar tissue without viable cancer cells was noted in the resected liver specimen. His postoperative course was uneventful, and recurrence has not been detected in the 30 months after surgery without adjuvant chemotherapy.

Conclusion

The present case report describes a successful strategy for advanced GC with pyloric stenosis and liver metastasis.

[A Surgical Case Report of Gastric Cancer Patient with Severe COPD Successfully Controlled by Preoperative Pulmonary Rehabilitation]

A 72-year-old man with a history of chronic obstructive pulmonary disease(COPD)was diagnosed with type 3 gastric cancer at the posterior wall of the gastric body. Although there was no distant metastasis in preoperative imaging tests, pulmonary function test revealed severe obstructive ventilatory impairment, suggesting that the patient had high risks of perioperative pulmonary complications. After treatment for COPD and preoperative pulmonary rehabilitation under hospitalization for 2 weeks, laparoscopic distal gastrectomy plus D2 lymphadenectomy plus Roux-en-Y reconstruction was performed. The patient showed stable respiratory condition postoperatively, and was discharged from hospital on postoperative day 12 without serious postoperative complications. It was suggested that preoperative pulmonary rehabilitation reduced postoperative pulmonary complications and allowed safe surgery in patients with severe COPD.

Morphological lymphocytic reaction, patient prognosis and PD-1 expression after surgical resection for oesophageal cancer

BACKGROUND

Immune checkpoint inhibitors, such as antibody against programmed cell death protein (PD-1), have demonstrated antitumour effects in patients with malignancies, including oesophageal cancer. A lymphocytic reaction observed by pathological examination is a manifestation of the host immune response to tumour cells. It was hypothesized that a stronger lymphocytic reaction to tumours might be associated with favourable prognosis in oesophageal cancer.

METHODS

Using a database of resected oesophageal cancers, four morphological components of lymphocytic reactions (peritumoral, intranest, lymphoid and stromal) to tumours were evaluated in relation to clinical outcome, PD-1 expression by immunohistochemistry and total lymphocyte count in blood.

RESULTS

Resected oesophageal cancer specimens from 436 patients were included in the study. Among the four morphological components, only peritumoral reaction was associated with patient prognosis (multivariable P for trend <0·001); patients with a higher peritumoral reaction had significantly longer overall survival than those with a lower reaction (multivariable hazard ratio 0·48, 95 per cent c.i. 0·34 to 0·67). The prognostic effect of peritumoral reaction was not significantly modified by other clinical variables (all P for interaction >0·050). Peritumoral reaction was associated with total lymphocyte count in the blood (P < 0·001), supporting the relationship between local immune response and systemic immune competence. In addition, higher morphological peritumoral reaction was associated with high PD-1 expression on lymphocytes in tumours (P = 0·034).

CONCLUSION

These findings should help to improve risk-adapted therapeutic strategies and help stratify patients in the future clinical setting of immunotherapy for oesophageal cancer.

[A Case of Curatively Resected Rectosigmoid Colon Cancer That Invaded the Urinary Bladder after Neoadjuvant Chemotherapy]

The patient was a 65-year-old man. His complaints included bloody stools and pain on urination. A detailed examination suggested vesical wall invasion, leading to a diagnosis of rectosigmoid cancer(cT4b, N+, M0). For R0 surgery, total cystectomy was considered necessary. To maintain vesical function, tumor-reducing chemotherapy was selected. After colostomy for the sigmoid colon, 4 courses of mFOLFOX6 plus bevacizumab therapy were administered. There was a marked reduction in the tumor size; therefore, 3 courses of mFOLFOX6 plus panitumumab therapy were administered as preoperative chemotherapy before resection. Partial response(PR)was achieved, and there was no urinary bladder infiltration. Therefore, surgery was performed. There was no tumor invasion to any other organ. High anterior rectal resection was performed. The pathological diagnosis also confirmed the efficacy of chemotherapy. We report about a patient in whom extended surgery could be avoided by administering chemotherapy for advanced rectosigmoid cancer with urinary bladder invasion.

Clinical utility of exhaled carbon monoxide in assessing preoperative smoking status and risks of postoperative morbidity after esophagectomy

Whereas smoking constitutes a significant risk factor for postesophagectomy morbidity, there is no reliable method to assess the smoking status of patients prior to the procedure. Since exhaled carbon monoxide (CO) is an indicator of recent smoking, this paper hypothesizes that this is a useful parameter in assessing current smoking status and may help predict morbidity following esophagectomy. Sixty-nine patients, who had undergone elective three-incision esophagectomy with two- or three-field lymphadenectomy for esophageal cancer, were prospectively studied between February 2015 and September 2017. At surgical admission, they were asked about their smoking history, their exhaled CO levels were evaluated, and they were grouped into three based on their CO levels. These were 0 parts per million (ppm), >0 and <7 ppm, and ≥7 ppm. Their postoperative morbidity was also assessed. Approximately 13.5% of the patients showed high levels of exhaled CO ≥ 7 ppm, despite preoperatively reporting smoking cessation for over a month. Morbidities of the Clavien-Dindo classification (CDc) ≥ II increased as exhaled CO levels increased and severe morbidity of CDc ≥ IIIb frequently was observed in patients with exhaled CO levels ≥7 ppm. The logistic regression analysis showed that exhaled CO level ≥7 ppm was an independent risk factor for severe postesophagectomy morbidity. Overall, the results of this study suggest that exhaled CO levels may be useful in estimating current smoking status and that it may also help give an estimation of the risk of postesophagectomy morbidity.

Minimally invasive esophagectomy may contribute to long-term respiratory function after esophagectomy for esophageal cancer

Evidence suggests that minimally invasive esophagectomy has several advantages with regard to short-term outcomes, compared to open esophagectomy in esophageal cancer patients. However, the impact of minimally invasive esophagectomy on long-term respiratory function remains unknown. The objective of this study is to assess the association between use of the minimally invasive esophagectomy and long-term respiratory dysfunction in esophageal cancer patients after esophagectomy. This retrospective single institution study using prospectively collected data included 87 consecutive esophageal cancer patients who had undergone esophagectomy. All patients underwent a respiratory function test before, and one year after esophagectomy. Logistic regression analysis was used to compute the hazard ratio for long-term respiratory dysfunction. Minimally invasive esophagectomies were performed in 53 patients, and open esophagectomies in 34 patients. The two groups showed no significant differences in terms of postoperative complications and postoperative course. Nor were any differences observed between the two groups in terms of volume capacity (L) and forced expiratory volume 1.0 (L) before esophagectomy (P > 0.34). However, one year after esophagectomy, the decreases in volume capacity and forced expiratory volume 1.0 were significantly less in the minimally invasive esophagectomy group than in the open esophagectomy group (P = 0.04 and P = 0.007, respectively). Multivariate analyses revealed that minimally invasive esophagectomy was an independent favorable factor for maintenance of forced expiratory volume 1.0 (hazard ratio = 0.17, 95% confidence interval 0.04-0.71; P = 0.01). Minimally invasive esophagectomy may be an independent favorable factor for maintenance of long-term respiratory function in esophageal cancer patients after esophagectomy.

Simultaneous Visualization of Vessels and Brain Tumor with Contrast-enhanced Three-dimensional Phase-contrast MR Imaging

The sequence for concurrently depicting engulfed vessels and a well-enhanced tumor in once-off scanning has never been reported for preoperative magnetic resonance imaging for brain tumor resection. Multimodal fusion techniques have been recently developed, but the risks of misregistration still remain. Here a case is reported where contrast-enhanced three-dimensional phase contrast sequence concurrently depicted an engulfed vessel and metastatic brain tumor in once-off scanning and related technical aspects are discussed.

Pyloroplasty may reduce weight loss 1 year after esophagectomy

Weight loss after esophagectomy is common and is associated with unfavorable prognosis. However, the clinical features and surgical methods that influence postesophagectomy weight loss are not well characterized. This study aims to determine those features (especially the surgical methods) that may affect postoperative weight loss. We reviewed 221 esophageal cancer patients who had undergone esophagectomy at Kumamoto University Hospital (Kumamoto, Japan) between November 2012 and June 2015. Among these, we recruited 106 patients who had undergone transthoracic esophagectomy with gastric conduit reconstruction, had no cancer recurrence within 1 year, and no missing follow-up data. We tabulated the body weight changes and risk factors associated with weight loss exceeding 10% at 1-year postesophagectomy. The mean body weights at baseline and 1-year postsurgery were 60.3 kg (standard error (SE): 0.91) and 52.6 (SE: 0.91), respectively. One year postsurgery, the body weights had changed as follows: mean: -12.2%; median: -12.9%; standard deviation: 9.06; range: -36.1-18.56%; interquartile range: -10.5 to -14.0%. In the multivariate logistic regression analysis, the absence of pyloroplasty was the sole risk factor for more than 10% weight loss (OR: 3.22; 95% CI: 1.08-11.9; P = 0.036). Our data suggest that pyloroplasty with esophagectomy can overcome the post-surgical weight loss.

[Usefulness of Laparoscopic Stoma Creation for Unresectable Colorectal Cancer]

Laparoscopic stoma creation enables good visualization of viscera within the abdominal cavity to ensure adequate mobilization of the large intestine. Laparoscopic stoma creation/construction was indicated and performed at our hospital in 7 patients who were diagnosed with unresectable colorectal cancer between July 2015 and May 2017. Duringthe ileostomy procedure, we made a skin incision at the stoma site and performed a single-incision(3-port)laparoscopic surgery. For the colostomy procedure, we made a small incision at the umbilicus and mobilized the large intestine with laparoscopic dissection of any interveningadhesions. Operation time ranged between 34 and 127 minutes, and the volume of intraoperative blood loss was low in all cases. There were no fatal complications related to the operation. Laparoscopic stoma creation can be performed safely and may be useful for staging of malignant colorectal tumors and reducing the risk of complications.

Monitoring sputum culture in resected esophageal cancer patients with preoperative treatment

Pneumonia is a major cause of postesophagectomy mortality and worsens the long-term survival in resected esophageal cancer patients. Moreover, preoperative treatments such as chemotherapy or chemoradiotherapy (which have recently been applied worldwide) might affect the bacterial flora of the sputum. To investigate the association among preoperative treatments, the bacterial flora of sputum, and the clinical and pathological features in resected esophageal cancer patients, this study newly investigates the effect of preoperative treatments on the bacterial flora of sputum. We investigated the association among preoperative treatments, the bacterial flora of sputum, and clinical and pathological features in 163 resected esophageal cancer patients within a single institution. Pathogenic bacteria such as Candida (14.1%), Staphylococcus aureus (6.7%), Enterobacter cloacae (6.1%), Haemophilus parainfluenzae (4.9%), Klebisiella pneumoniae (3.7%), Methicillin-resistant Staphylococcus aureus (MRSA) (3.7%), Pseudomonas aeruginosa (2.5%), Escherichia coli (1.8%), Streptococcus pneumoniae (1.8%), and Haemophilus influenzae (1.2%) were found in the sputum. The pathogen detection rate in the present study was 34.3% (56/163). In patients with preoperative chemotherapy and chemoradiotherapy, the indigenous Neisseria and Streptococcus species were significantly decreased (P= 0.04 and P= 0.04). However, the detection rates of pathogenic bacteria were not associated with preoperative treatments (all P> 0.07). There was not a significant difference of hospital stay between the sputum-monitored patients and unmonitored patients (35.5 vs. 49.9 days; P= 0.08). Patients undergoing preoperative treatments exhibited a significant decrease of indigenous bacteria, indicating that the treatment altered the bacterial flora of their sputum. This finding needs to be confirmed in large-scale independent studies or well-designed multicenter studies.

Use of PIXE/PIGE for sequential Ca and F measurements in root carious model

The progress of caries has conventionally been evaluated by checking changes in mineral density using transverse microradiography (TMR). Recent advances have seen development of a new measurement system, using in-air micro proton induced X-ray/gamma-ray emission (PIXE/PIGE). PIXE/PIGE enables analysis of distributions and concentrations of multiple mineral elements in a carious lesion. The aim of this study was to evaluate the effectiveness of PIXE/PIGE for investigating the development of root caries. In summary, we successfully established a multi-elemental sequential measuring method using in-air micro-PIXE/PIGE to identify the dynamic distributions and concentrations of Ca and F in human root dentin. The PIXE/PIGE potentially offers a useful advantageous technique for studying carious development by using as a combination with conventional techniques such as TMR and Micro-computed tomography (µCT).

Prognostic and clinical impact of sarcopenia in esophageal squamous cell carcinoma

Recently, depletion of skeletal muscle mass (sarcopenia) has been linked to poor prognosis in several types of cancers, but has not been investigated in esophageal squamous cell carcinoma (ESCC). This retrospective study investigates the relationship between sarcopenia and clinical outcome in ESCC patients treated by surgical resection or definitive chemoradiation therapy (dCRT). The study was retrospectively conducted in a single academic hospital in Kumamoto, Japan, and involved 325 ESCC patients (256 surgical cases and 69 dCRT cases) treated between April 2005 and April 2011. Skeletal muscle mass was quantified by radiologic measures using standard computed tomography scans. The skeletal muscle tissue in the 325 ESCC patients was distributed as follows: mean: 47.10; median: 46.88; standard deviation (SD): 7.39; range: 31.48-71.11; interquartile range, 46.29-47.90. Skeletal muscle tissue was greater in male patients than in female patients (P < 0.0001), but was independent of other clinical and tumor features. Sarcopenia was not significantly associated with overall survival (log rank P = 0.54). Lymph node involvement significantly altered the relationship between sarcopenia and survival rate (P for interaction = 0.026). Sarcopenia significantly reduced the overall survival of patients without lymph node involvement (log rank P = 0.035), but was uncorrelated with overall survival in patients with lymph involvement (log rank, P = 0.31). The anastomosis leakage rate was significantly higher in the sarcopenia group than in the non-sarcopenia group (P = 0.032), but other surgical complications did not significantly differ between the two groups. Sarcopenia in ESCC patients without lymph node involvement is associated with poor prognosis, indicating sarcopenia as a potential biomarker for identifying patients likely to experience an inferior outcome. Moreover, sarcopenia was associated with anastomosis leakage but no other short-term surgical outcome.

Modified high dorsal procedure for performing isolated anatomic total caudate lobectomy (with video)

Background

Isolated anatomic total caudate lobectomy is indicated in patients who have liver tumors limited to the caudate lobe. However, isolated caudate lobe resection is a challenging surgical procedure that required safe and reliable techniques. All portal and hepatic veins that connect this area originate from the first branch of the portal vein or vena cava; therefore, the operator must be cautious of the potential for massive bleeding.

Methods

The important points regarding the safety of our procedure include creating an optimal surgical view and preparing for accidental bleeding before parenchymal dissection. Sufficient mobilization and removal of Spiegel’s lobe from the left to the right side of the vena cava allows the operator to perform parenchymal dissection under a right- or front-side view.

Results

We have performed this technique in two patients with HCC and one patient with primary cystadenocarcinoma. The average operative time and amount of blood loss were 435 min and 1137 ml, respectively. No operative mortalities or postoperative complications were observed in any of the patients. Our three patients are currently doing well without any recurrence.

Conclusion

Our modified high dorsal resection procedure can be used to safely remove the entire caudate lobe.

Electronic supplementary material

The online version of this article (doi:10.1186/s12957-016-0896-3) contains supplementary material, which is available to authorized users.

[A Case of Adult Invagination Caused by Rectal Cancer]

An 87-year-old man visited our hospital with a chief complaint of melena. Invagination caused by rectal cancer or sigmoid colon cancer was suspected as a result of physical and radiological examinations. Since there were no subjective symptoms, laparoscopic surgery was planned electively. As an operative finding, a tumor was found in the rectosigmoid colon and caused invagination. The invagination was released during an operation, and high anterior resection with D3 dissection was performed laparoscopically. The operation time was 108 minutes and the amount of blood loss was 22 mL. Although anastomotic leakage occurred as a postoperative complication, recovery was achieved conservatively by percutaneous drainage. In many cases, invagination of adults is caused by a solid tumor such as bowel carcinoma, which commonly occurs at the cecum or sigmoid colon. Although invagination of the rectosigmoid colon fixed to the retroperitoneum is relatively rare, the fragility of the supporting tissues in the pelvis accompanied by aging is considered to be a cause. In cases of a large tumor occupying the lumen of the intestine, appropriate preoperative diagnosis is needed and the method of operation should be chosen carefully.

[Successful Treatment of Stenosis of the Portal Vein Using an Expandable Metallic Stent after Extended Right Hepatectomy--A Case Report]

We report successful treatment of stenosis of the portal vein caused by enlargement of the remnant liver after extended right hepatectomy with interventional radiology using an intraportal expandable metallic stent (EMS). A 75-year-old man underwent extended right hepatectomy after percutaneous transhepatic right portal embolization for advanced gallbladder cancer. His portal vein branched out into the anterior, posterior, and left branches. The main portal vein and left branch formed a sharp angle by nature. We ligated the posterior branch and sutured the cut line of the anterior branch during surgery. Several days after the surgery, icterus and massive ascites developed. Computed tomography (CT) and portography showed thrombi and stenosis of the cut line of the right branches due to enlargement of the remnant liver. A covered EMS was placed at the stenosis with interventional radiology. After stent placement, the icterus and massive ascites resolved. The patient remains well and EMS has caused no difficulty for 19 months. Intraportal EMS placement is effective in treating perioperative portal venous complications.

Prognostic impact of hepatectomy for patients with non-hepatitis B, non-hepatitis C hepatocellular carcinoma

BACK GROUND/AIM: The purpose of the present study was to clarify the clinicopathological features of non-hepatitis B and -C (NBNC) hepatocellular carcinoma (HCC), the incidence of which has been increasing.

PATIENTS AND METHODS

Two hundred and eighty-four patients with HCC were classified into three groups according to viral hepatitis status, namely NBNC, hepatitis B, and hepatitis C. We compared the three groups and studied related risk factors.

RESULTS

Patients without cirrhosis who had increased number of platelets and diabetes mellitus, and a serum alpha-feto-protein (AFP) level <100 ng/dl were more common in the NBNC group. The cumulative survival and disease-free survival were better in the NBNC group than in the other groups. The tumor size and hepatitis B or C viral status were found to be independent risk factors of disease-free survival and the presence of multiple lesions was the only independent risk factor of survival.

CONCLUSION

Close follow-up of NBNC liver cirrhosis and early detection of NBNC-HCC can improve the prognosis after surgery.

Modified gastric pull-up reconstructions following pharyngolaryngectomy with total esophagectomy

Reconstruction following pharyngolaryngectomy with total esophagectomy is a challenging surgery to perform. Between April 2008 and August 2012, three types of modified gastric pull-up reconstruction procedures, including a gastric tube creation combined with a free jejunal transfer (n = 7), elongated gastric tube creation with vascular anastomoses (n = 2) and pedunculated gastric tube creation with Roux-en-Y anastomosis (n = 5), were performed after pharyngolaryngectomy with total esophagectomy. To clarify feasibility of these reconstructive methods, we retrospectively analyzed the short-term outcomes. There were no graft failures. Salivary fistulae were observed in two cases after high pharyngoenteral anastomoses due to oropharyngeal extension of hypopharyngeal cancers. Overall morbidity rate was 21.4%, and no deaths occurred. Although the operation time was shortest for pedunculated gastric tube reconstructions, morbidity rates were similar among all methods. All three types of modified gastric pull-up reconstruction procedures can be performed safely. We can choose one of these methods according to the tumor status and the patient condition, understanding advantages and disadvantages of each procedure.

Plasma CD147 reflects histological features in patients with lupus nephritis

OBJECTIVE

A glycosylated transmembrane protein, CD147, has been implicated in regulating lymphocyte responsiveness and leukocyte recruitment. As lupus nephritis (LN) often follows a relapsing-remitting disease course, accurate understanding of the disease activity would be extremely helpful in improving prognosis. Unfortunately, neither clinical nor serological data can accurately reflect the histological features of LN. The present study investigated whether CD147 can accurately predict pathological features of LN.

METHODS

Plasma and spot urine samples were collected from 64 patients who underwent renal biopsy between 2008 and 2011. Disease activity for LN tissues was evaluated using the biopsy activity index, and compared to levels of biomarkers including CD147.

RESULTS

In LN tissues, CD147 induction was striking in injured glomeruli and infiltrating inflammatory cells, but not in damaged tubules representing atrophy. Plasma CD147 levels accurately reflected the histological disease activity. However, prediction using a single molecule would be quite difficult because of the complex pathogenesis of LN. The diagnostic accuracy of multiplex parameters indicated that the combination including plasma CD147 might yield excellent diagnostic abilities for guiding ideal LN therapy.

CONCLUSION

Plasma CD147 levels might offer useful insights into disease activity as a crucial biomarker in patients with LN.

Radiofrequency ablation for pulmonary metastases from esophageal squamous cell carcinoma

Radiofrequency ablation (RFA) is increasingly being used for the treatment of intrathoracic malignancies. Although RFA has been found to be promising in the treatment of lung metastases from some types of neoplasms, little is known concerning its clinical significance in the treatment of pulmonary metastasis from esophageal squamous cell carcinoma (ESCC). This retrospective study evaluated the feasibility, safety, and effectiveness of computed tomography-guided RFA for pulmonary metastasis from ESCC. A series of 10 ESCC patients with 17 pulmonary tumors were included. Correct placement of the ablation device into the target tumor proved to be feasible in all tumors (100%). The mean visual analog scale score, with values that ranged from 0 (no pain) to 10 (worst pain possible), was 1. This suggested that this procedure was well tolerated. No procedure-related deaths occurred. A pneumothorax needing drainage was a major complication in two patients. Local control of ablated tumor lasting for at least 1 year was achieved in 10 (83%) of 12 assessable tumors. Although locoregional recurrences developed in two tumors, these lesions could be recontrolled by repeat treatment with RFA. Three patients died of recurrent disease. The predicted 1- and 2-year overall survival rates after lung RFA were 77.8% and 62.2%, respectively. Percutaneous computed tomography-guided RFA yielded relatively high levels of local control in patients with pulmonary metastases from ESCC and was associated with an acceptable level of complications. It was concluded that a prospective study will be necessary to evaluate the effectiveness of a combination of systemic therapy and RFA for ESCC lung metastases.

CD44s signals the acquisition of the mesenchymal phenotype required for anchorage-independent cell survival in hepatocellular carcinoma

Background:

Circulating tumour cells (CTCs) have an important role in metastatic processes, but details of their basic characteristics remain elusive. We hypothesised that CD44-expressing CTCs show a mesenchymal phenotype and high potential for survival in hepatocellular carcinoma (HCC).

Methods:

Circulating CD44⁺CD90⁺ cells, previously shown to be tumour-initiating cells, were sorted from human blood and their genetic characteristics were compared with those of tumour cells from primary tissues. The mechanism underlying the high survival potential of CD44-expressing cells in the circulatory system was investigated in vitro.

Results:

CD44⁺CD90⁺ cells in the blood acquired epithelial–mesenchymal transition, and CD44 expression remarkably increased from the tissue to the blood. In Li7 and HLE cells, the CD44^high population showed higher anoikis resistance and sphere-forming ability than did the CD44^low population. This difference was found to be attributed to the upregulation of Twist1 and Akt signal in the CD44^high population. Twist1 knockdown showed remarkable reduction in anoikis resistance, sphere formation, and Akt signal in HLE cells. In addition, mesenchymal markers and CD44s expression were downregulated in the Twist1 knockdown.

Conclusions:

CD44s symbolises the acquisition of a mesenchymal phenotype regulating anchorage-independent capacity. CD44s-expressing tumour cells in peripheral blood are clinically important therapeutic targets in HCC.

E2F5 as an independent prognostic factor in esophageal squamous cell carcinoma

BACKGROUND

E2F Transcription Factor 5 Protein (E2F5) is considered to act primarily as a transcriptional repressor in the cell cycle. However, its expression and role in esophageal squamous cell carcinoma (ESCC) have not been investigated. We examined whether the expression of E2F5 is related to the clinicopathological features and prognosis of patients with ESCC.

MATERIALS AND METHODS

The expression of E2F5 was analyzed by immunohistochemistry in 64 primary tumor samples obtained from patients with ESCC who had undergone curative esophagectomy between 1998 and 2009. According to the expression of E2F5 in tumor cells, cases were divided into E2F5-positive (27 cases) and -negative groups (37 cases). The relationship of various clinicopathological features and prognosis with the E2F5 status, were analyzed.

RESULTS

In the clinicopathological analysis, the proportion of poorly-differentiated tumors was significantly higher in the E2F5-positive group than in the E2F5-negative group (p=0.027). The 5-year survival rate of the E2F5-positive group was 39.3%, which was significantly poorer than that of the E2F5-negative group (83.8%) (p=0.006). In multivariate analysis, the expression of E2F5 was one of the most important independent prognostic factors after radical esophagectomy.

CONCLUSION

The expression of E2F5 in ESCC may be correlated with a worse prognosis of patients with ESCC.

[Laparoscopic lateral lymph node dissection technique and short-term results in our hospital]

We perform preoperative chemoradiotherapy for patients with advanced lower rectal cancer in our department. In April 2012, we started laparoscopic lateral lymph node dissection for preventive dissection in patients without lateral lymph node enlargement on preoperative diagnosis. We compared the short-term results of laparoscopic lateral dissection with those of laparotomy.

SUBJECTS

The subjects comprised 43 patients undergoing lateral dissection by laparotomy( open group) and 5 patients undergoing laparoscopic lateral dissection (lap group).

RESULTS

There were no significant differences in the baseline characteristics of patients between the lap group and the open group. However, operative time (min) was significantly longer( 536.2 vs 324.8) and the volume of blood loss( g) was significantly lower( 139.0 vs 697.8) in the lap group. No significant differences were observed in the number of dissected lymph nodes, postoperative complications, or the duration of hospital stay.

CONCLUSION

Although the operative time was longer with laparoscopy-assisted lateral lymph node dissection, this procedure was safely performed with minimal blood loss. Our findings confirmed that there were no problems with standardization of this technique or oncological outcomes, and hence, we are examining the indications for therapeutic dissection.

[An appropriate distal resection margin for lower rectal cancer after preoperative chemoradiotherapy]

In recent years, with the increase in the adoption of anus-preserving surgery, understanding of residual lower rectal cancer distribution to the anal side after chemoradiotherapy (CRT) has become an increasingly important issue. We aimed to clarify the pathological safe distal resection margin for lower rectal cancer after preoperative CRT. This study included 36 patients with lower third rectal cancer, who underwent preoperative CRT. We classified the gross tumor appearance as type 0-II like, Borrmann type 2, and Borrmann type 5. Whole-mount sections were used for pathological examination. We examined all slides and measured the extent of residual cancer spread. In many cases, residual cancer was observed in the deeper layers of the lesion, and in none of the cases was the cancer limited to the superficial layer. With regard to lateral distribution, tumors with a type 0-II like appearance showed a wider extent of lateral cancer spread from the optimal margin. In conclusion, although CRT contributes to tumor reduction, attention should be paid to both circumferential and lateral residual cancer spread. Our results suggest that the lateral distribution of residual cancer spread could be predicted by gross tumor appearance. This is an ongoing study.

Influence of preoperative docetaxel, cisplatin, and 5-fluorouracil on the incidence of complications after esophagectomy for resectable advanced esophageal cancer

A limited number of patients with resectable advanced esophageal cancer can be cured by surgery alone. Although a regimen that consists of docetaxel, cisplatin, and 5-fluorouracil (DCF) is a potential preoperative chemotherapy (PCT) option for squamous cell carcinoma of the esophagus, the influence of DCF on subsequent esophagectomies remains unclear. A total of 80 patients who received preoperative DCF chemotherapy, and 174 patients who did not receive any preoperative treatment were retrospectively analyzed. There were no treatment-related deaths. No delays in surgery due to adverse events related to DCF were reported. Although patients who received PCT had significantly more advanced cancers and worse preoperative conditions, the incidence rates of complications did not increase. Although the frequency of severe complications was significantly higher in patients who received PCT, this treatment was not an independent factor for the occurrence of severe complications. PCT with DCF did not negatively affect subsequent esophagectomies with regard to the frequency of complications.

Methylation levels of LINE-1 in primary lesion and matched metastatic lesions of colorectal cancer

Background:

LINE-1 methylation level is a surrogate marker of global DNA methylation. LINE-1 methylation in primary colorectal cancers (CRCs) is highly variable and strongly associated with a poor prognosis. However, no study has examined LINE-1 methylation levels of metastatic CRCs in relation to prognosis or assessed the heterogeneity of LINE-1 methylation level within the primary CRCs.

Methods:

Pyrosequencing was used to quantify LINE-1 methylation level in 42 liver metastases, 26 matched primary tumours, and 6 matched lymph node (LN) metastases. KRAS, BRAF, and PIK3CA mutation status and microsatellite instability (MSI) status were also examined.

Results:

The distribution of LINE-1 methylation level in liver metastases was as follows: mean, 67.3; range, 37.1–90.1. Primary tumours showed LINE-1 methylation levels similar to those of matched liver and LN metastases. The difference in LINE-1 methylation level between superficial areas and invasive front areas was within 7.0 in all six cases evaluated. Prognostic impact of LINE-1 hypomethylation in liver metastases on overall survival was not observed. The concordance rate was 94% for KRAS, 100% for BRAF, 88% for PIK3CA, and 97% for MSI.

Conclusion:

Alteration of LINE-1 methylation level may occur in early CRC tumorigenesis, and the LINE-1 methylation level is relatively stable during CRC progression.

XB130 as an independent prognostic factor in human esophageal squamous cell carcinoma

BACKGROUND

Adaptor proteins, with multimodular structures, can participate in the regulation of various cellular functions. A novel adaptor protein XB130 has been implicated as a substrate and regulator of tyrosine kinase-mediated signaling and in controlling cell proliferation and apoptosis in thyroid and lung cancer cells. However, its expression and role in gastrointestinal cancer have not been investigated. We sought to determine the role of XB130 in cell cycle progression of esophageal squamous cell carcinoma (ESCC) cells and to examine its expression and effects on the prognosis of patients with ESCC.

METHODS

Expression of XB130 in human ESCC cell lines was analyzed by Western blot testing and immunofluorescent staining. Knockdown experiments with XB130 small interfering RNA (siRNA) were conducted, and the effect on cell cycle progression was analyzed. Immunohistochemistry of XB130 for 52 primary tumor samples obtained from patients with ESCC undergoing esophagectomy was performed.

RESULTS

XB130 was highly expressed in TE2, TE5, and TE9 cells. In these cells, knockdown of XB130 with siRNA inhibited G1-S phase progression and increased the expression of p21, the cyclin-dependent kinase inhibitor. Immunohistochemistry showed that 71.2% of the patients expressed XB130 in the nuclei and/or cytoplasm of the ESCC cells. Further, nuclear expression of XB130 was an independent prognostic factor of postoperative survival.

CONCLUSIONS

These observations suggest that the expression of XB130 in ESCC cells may affect cell cycle progression and impact prognosis of patients with ESCC. A deeper understanding of XB130 as a mediator and/or biomarker in ESCC is needed.

[Lumbar spinal nerve roots imaging using balanced sequence with inversion recovery (IR) pulse]

We devised a method for visualizing the distal portion of lumbar spinal nerve roots in the direction of the long axis using a three-dimensional balanced sequence with inversion recovery pulse, and we established the imaging parameters. This pulse sequence was used with the following parameters: 260 mm field of view, 4.8 ms repetition time, 2.4 ms echo time, 90 degree flip angle, 1.5 mm slice thickness (0.75 mm overlap), and low-high radial k-space profile order. We assessed the signal intensity and contrast for the phantom and healthy volunteer images with different inversion times (TI). Moreover, we evaluated this method by using the optimal TI in clinical cases. The optimal TI obtained from the phantom and human studies was 600 ms. In clinical cases, this method with 600 ms of TI provided the best definition in images of abnormal pathway and compression of the lumbar spinal nerve roots. Our imaging method makes it possible to clearly and noninvasively visualize the lumbar spinal nerve roots.