Risk of metachronous colorectal cancer after surgical resection of index rectal cancer in Lynch syndrome: a multicenter retrospective study in Japan

PURPOSE

This study evaluated the risk of metachronous colorectal cancer (CRC) after resection of index (first) rectal cancer in patients with Lynch syndrome (LS).

METHODS

Clinicopathological data of patients with genetically proven LS were retrospectively analyzed in this multicenter Japanese study. The cumulative incidence of metachronous CRC and the overall survival were compared between patients with index rectal cancer (rectal group) and those with index colon cancer (colon group).

RESULTS

The median age at index CRC surgery was lower in the rectal group than in the colon group (37 vs. 46 years old, P = 0.01). The cumulative 5-, 10-, and 20-year incidences of metachronous CRC were 3.5%, 13.9%, and 21.1%, respectively, in the rectal cancer group and 14.9%, 22.0%, and 57.9%, respectively, in the colon cancer group (P = 0.02). The overall survival curves were not significantly different between two groups (P = 0.23).

CONCLUSION

This is the first report from an East Asian country to report the risk of metachronous CRC after resection of index rectal cancer in patients with LS. Despite this study having several limitations, we cannot recommend extended resection, such as total proctocolectomy, for index rectal cancer as a standard surgical treatment in patients with LS.

High-Fat Diet-Induced Diabetic Conditions Exacerbate Cognitive Impairment in a Mouse Model of Alzheimer's Disease Via a Specific Tau Phosphorylation Pattern

BACKGROUND

Epidemiological evidence has demonstrated a clear association between diabetes mellitus and increased risk of Alzheimer's disease (AD). Cerebral accumulation of phosphorylated tau aggregates, a cardinal neuropathological feature of AD, is associated with neurodegeneration and cognitive decline. Clinical and experimental studies indicate that diabetes mellitus affects the development of tau pathology; however, the underlying molecular mechanisms remain unknown.

OBJECTIVE

In the present study, we used a unique diabetic AD mouse model to investigate the changes in tau phosphorylation patterns occurring in the diabetic brain.

DESIGN

Tau-transgenic mice were fed a high-fat diet (n = 24) to model diabetes mellitus. These mice developed prominent obesity, severe insulin resistance, and mild hyperglycemia, which led to early-onset neurodegeneration and behavioral impairment associated with the accumulation of hyperphosphorylated tau aggregates.

RESULTS

Comprehensive phosphoproteomic analysis revealed a unique tau phosphorylation signature in the brains of mice with diabetic AD. Bioinformatic analysis of the phosphoproteomics data revealed putative tau-related kinases and cell signaling pathways involved in the interaction between diabetes mellitus and AD.

CONCLUSION

These findings offer potential novel targets that can be used to develop tau-based therapies and biomarkers for use in AD.

Genotype-phenotype correlation for extracolonic aggressive phenotypes in patients with familial adenomatous polyposis

Familial adenomatous polyposis (FAP) patients develop various life-threatening extracolonic comorbidities that appear individually or within a family. This diversity can be explained by the localization of the adenomatous polyposis coli (APC) variant, but few reports provide definitive findings about genotype-phenotype correlations. Therefore, we investigated FAP patients and the association between the severe phenotypes and APC variants. Of 247 FAP patients, 126 patients from 85 families identified to have APC germline variant sites were extracted. These sites were divided into six groups (Regions A to F), and the frequency of severe comorbidities was compared among the patient phenotypes. Of the 126 patients, the proportions of patients with desmoid tumor stage ≥III, number of FGPs ≥1000, multiple gastric neoplasms, gastric neoplasm with high-grade dysplasia, and Spigelman stage ≥III were 3%, 16%, 21%, 12%, and 41%, respectively, while the corresponding rates were 30%, 50%, 70%, 50%, and 80% in patients with Region E (codons 1398-1580) variants. These latter rates were significantly higher than those for patients with variants in other regions. Moreover, the proportion of patients with all three indicators (desmoid tumor stage ≥III, number of FGPs ≥1000, and Spigelman stage ≥III) was 20% for those with variants in Region E and 0% for those with variants in other regions. Variants in Region E indicate aggressive phenotypes, and more intensive management is required.

Risk of metachronous colorectal cancer after colectomy for first colon cancer in Lynch syndrome: multicenter retrospective study in Japan

BACKGROUND

We evaluated the risk of metachronous colorectal cancer (mCRC) and explored the optimal extent of colectomy in patients with Lynch syndrome (LS) and first colon cancer (fCC) in Japan, where the extent of colectomy for colon cancer (CC) is shorter than that in Western countries.

METHODS

The clinicopathologic and survival data of patients with LS who developed CC were collected from a nationwide database and analyzed retrospectively. The cumulative incidence of mCRC after actual segmental colectomy was compared with that of mCRC when more extensive colectomy was assumed.

RESULTS

There were 142 eligible patients (65 female). The median age at fCC surgery was 46.5 (range: 14-80) years. The cumulative incidence of 5-, 10-, and 20-year mCRC rate was 13.4%, 20.8%, and 53.6%, respectively. The incidence was higher in the left-sided group (splenic flexure to rectosigmoid colon, n = 54) than in the right-sided group (cecum to transvers colon, n = 88) (66.3% vs. 45.3% in 20 years, P < 0.01). Assuming that all patients would have undergone hemicolectomy or total colectomy, the estimated mCRC risk was 41.5% and 9.4% (P < 0.01, vs. actual procedures), respectively. The 20-year overall survival rate of all the patients was 83.3% without difference by fCC sidedness (P = 0.38).

CONCLUSIONS

To reduce the incidence of mCRC, patients with genetically diagnosed LS and fCC, preferentially located in the left-sided colon, may need to undergo more extended colectomy than that usually performed in Japan. However, such extended colectomy should be counterbalanced with favorable overall survival and actual risk of mCRC development.

Dual-floor Burr Hole Technique Optimized for Modern Burr Hole Caps with an Internal Electrode Locking Mechanism

Insertion of a deep brain stimulating electrode is a commonly performed procedure. Burr hole caps play an important role in this procedure by immobilizing this electrode; however, burr hole caps could form scalp bumps, which can create further complications. The dual-floor burr hole technique could prevent the formation of scalp bumps. This technique has previously been used with older versions of burr hole caps and has proved to be successful. In recent years, modern burr hole caps with an internal electrode locking mechanism have become the mainstay for this procedure. However, modern burr hole caps differ considerably in diameter and shape from older burr hole caps. In the present study, a dual-floor burr hole technique was performed using modern burr hole caps. To accommodate the increase in diameters and changes in the shape of modern burr hole caps, a perforator with a 30-mm diameter was used for shaving the bone, and the bone shaving depth was altered. This surgical technique was applied to 23 consecutive deep brain stimulation surgeries without complications and was thus positively optimized for modern burr hole caps.

A complex rearrangement between APC and TP63 associated with familial adenomatous polyposis identified by multimodal genomic analysis: a case report

Genetic testing of the APC gene by sequencing analysis and MLPA is available across commercial laboratories for the definitive genetic diagnosis of familial adenomatous polyposis (FAP). However, some genetic alterations are difficult to detect using conventional analyses. Here, we report a case of a complex genomic APC-TP63 rearrangement, which was identified in a patient with FAP by a series of genomic analyses, including multigene panel testing, chromosomal analyses, and long-read sequencing. A woman in her thirties was diagnosed with FAP due to multiple polyps in her colon and underwent total colectomy. Subsequent examination revealed fundic gland polyposis. No family history suggesting FAP was noted except for a first-degree relative with desmoid fibromatosis. The conventional APC gene testing was performed by her former doctor, but no pathogenic variant was detected, except for 2 variants of unknown significance. The patient was referred to our hospital for further genetic analysis. After obtaining informed consent in genetic counseling, we conducted a multigene panel analysis. As insertion of a part of the TP63 sequence was detected within exon16 of APC, further analyses, including chromosomal analysis and long-read sequencing, were performed and a complex translocation between chromosomes 3 and 5 containing several breakpoints in TP63 and APC was identified. No phenotype associated with TP63 pathogenic variants, such as split-hand/foot malformation (SHFM) or ectrodactyly, ectodermal dysplasia, or cleft lip/palate syndrome (EEC) was identified in the patient or her relatives. Multimodal genomic analyses should be considered in cases where no pathogenic germline variants are detected by conventional genetic testing despite an evident medical or family history of hereditary cancer syndromes.

Higher prefrontal activity based on short-term neurofeedback training can prevent working memory decline in acute stroke

This study aimed to clarify whether short-term neurofeedback training during the acute stroke phase led to prefrontal activity self-regulation, providing positive efficacy to working memory. A total of 30 patients with acute stroke performed functional near-infrared spectroscopy-based neurofeedback training for a day to increase their prefrontal activity. A randomized, Sham-controlled, double-blind study protocol was used comparing working memory ability before and after neurofeedback training. Working memory was evaluated using a target-searching task requiring spatial information retention. A decline in spatial working memory performance post-intervention was prevented in patients who displayed a higher task-related right prefrontal activity during neurofeedback training compared with the baseline. Neurofeedback training efficacy was not associated with the patient's clinical background such as Fugl-Meyer Assessment score and time since stroke. These findings demonstrated that even short-term neurofeedback training can strengthen prefrontal activity and help maintain cognitive ability in acute stroke patients, at least immediately after training. However, further studies investigating the influence of individual patient clinical background, especially cognitive impairment, on neurofeedback training is needed. Current findings provide an encouraging option for clinicians to design neurorehabilitation programs, including neurofeedback protocols, for acute stroke patients.

Clinical Guidelines for Diagnosis and Management of Peutz-Jeghers Syndrome in Children and Adults

BACKGROUND

Peutz-Jeghers syndrome (PJS) is a rare disease characterized by the presence of hamartomatous polyposis throughout the gastrointestinal tract, except for the esophagus, along with characteristic mucocutaneous pigmentation. It is caused by germline pathogenic variants of the STK11 gene, which exhibit an autosomal dominant mode of inheritance. Some patients with PJS develop gastrointestinal lesions in childhood and require continuous medical care until adulthood and sometimes have serious complications that significantly reduce their quality of life. Hamartomatous polyps in the small bowel may cause bleeding, intestinal obstruction, and intussusception. Novel diagnostic and therapeutic endoscopic procedures such as small-bowel capsule endoscopy and balloon-assisted enteroscopy have been developed in recent years.

SUMMARY

Under these circumstances, there is growing concern about the management of PJS in Japan, and there are no practice guidelines available. To address this situation, the guideline committee was organized by the Research Group on Rare and Intractable Diseases granted by the Ministry of Health, Labour and Welfare with specialists from multiple academic societies. The present clinical guidelines explain the principles in the diagnosis and management of PJS together with four clinical questions and corresponding recommendations based on a careful review of the evidence and involved incorporating the concept of the Grading of Recommendations Assessment, Development and Evaluation system.

KEY MESSAGES

Herein, we present the English version of the clinical practice guidelines of PJS to promote seamless implementation of accurate diagnosis and appropriate management of pediatric, adolescent, and adult patients with PJS.

Augmented Reality in Stereotactic Neurosurgery: Current Status and Issues

Stereotactic neurosurgery is an established technique, but it has several limitations. In frame-based stereotaxy using a stereotactic frame, frame setting errors may decrease the accuracy of the procedure. Frameless stereotaxy using neuronavigation requires surgeons to shift their view from the surgical field to the navigation display and to advance the needle while assuming a physically uncomfortable position. To overcome these limitations, several researchers have applied augmented reality in stereotactic neurosurgery. Augmented reality enables surgeons to visualize the information regarding the target and preplanned trajectory superimposed over the actual surgical field. In frame-based stereotaxy, a researcher applies tablet computer-based augmented reality to check for the setting errors of the stereotactic frame, thereby improving the safety of the procedure. Several researchers have reported performing frameless stereotaxy guided by head-mounted-display-based augmented reality that enables surgeons to advance the needle at a more natural posture. These studies have shown that augmented reality can address the limitations of stereotactic neurosurgery. Conversely, they have also revealed the limited accuracy of current augmented reality systems for small targets, which indicates that further development of augmented reality systems is needed.

Genotype-phenotype correlation of small-intestinal polyps on small-bowel capsule endoscopy in familial adenomatous polyposis

BACKGROUND AND AIMS

In familial adenomatous polyposis (FAP), neoplastic lesions outside the colon have become increasingly important. The genotype-phenotype correlation has been established for duodenal polyps, and regular screening is recommended. However, this correlation remains unclear for small-intestinal lesions, except for reports on the relationship between their occurrence and Spigelman stage. Here, we used small-bowel capsule endoscopy (SBCE) to investigate the genotype-phenotype correlation of small-intestinal polyps in FAP.

METHODS

The genotype-phenotype correlation of small-intestinal polyps was investigated in patients with FAP who underwent SBCE, Esophagogastroduodenoscopy (EGD), and adenomatous polyposis coli (APC) gene analysis. Of 64 patients with FAP who underwent SBCE, 41 were included in the final analysis, 4 did not undergo a complete small intestine examination, and 19 did not undergo genetic analysis.

RESULTS

The prevalence (median number) of small-intestinal polyps by Spigelman stage was 26% (1.5), 0% (0), 44% (5), 60% (4), and 73% (25.5) for stages 0 to IV, respectively. Significantly more small-intestinal polyps were found in Spigelman stage III and IV groups than in the stage 0 group (P < .05). The APC variant was negative for 6 patients (15%), and the sites associated with more than 5 small-intestinal polyps were codons 278, 1062, 1114, 1281, 1307, 1314, and 1504.

CONCLUSIONS

In FAP patients, SBCE surveillance is potentially recommended for patients with pathogenic variants in the APC gene at codons 278 and 1062 to 1504 or with Spigelman stage III or higher.

Early distribution of18 F-labeled AAV9 vectors in the cerebrospinal fluid after intracerebroventricular or intracisternal magna infusion in non-human primates

BACKGROUND

The delivery of adeno-associated virus (AAV) vectors via the cerebrospinal fluid (CSF) has emerged as a valuable method for widespread transduction in the central nervous system. Although infusion into the cerebral ventricles is a common protocol in preclinical studies of small animals, the cisterna magna has been recognized as an alternative target for clinical studies because it can be reached in a less invasive manner using an intrathecal catheter via the subarachnoid space from a lumbar puncture.

METHODS

We evaluated the early distribution of fluorine-18-labeled AAV9 vectors infused into the lateral ventricle or cisterna magna of four non-human primates using positron emission tomography. The expression of the green fluorescent protein was immunohistochemically determined.

RESULTS

In both approaches, the labeled vectors diffused into the broad arachnoid space around the brain stem and cervical spinal cord within 30 min. Both infusion routes efficiently transduced neurons in the cervical spinal cord.

CONCLUSIONS

For gene therapy that primarily targets the cervical spinal cord and brainstem, such as amyotrophic lateral sclerosis, cisterna magna infusion would be a feasible and effective administration method.

Intensive endoscopic resection for downstaging of polyp burden in patients with familial adenomatous polyposis (J-FAPP Study III): a multicenter prospective interventional study

BACKGROUND

Total colectomy is the standard treatment for familial adenomatous polyposis (FAP). Recently, an increasing number of young patients with FAP have requested the postponement of surgery or have refused to undergo surgery. We aimed to evaluate the effectiveness of intensive endoscopic removal for downstaging of polyp burden (IDP) in FAP.

METHOD

A single-arm intervention study was conducted at 22 facilities. Participants were patients with FAP, aged ≥ 16 years, who had not undergone colectomy or who had undergone colectomy but had ≥ 10 cm of large intestine remaining. For IDP, colorectal polyps of ≥ 10 mm were removed, followed by polyps of ≥ 5 mm. The primary end point was the presence/absence of colectomy during a 5-year intervention period.

RESULTS

222 patients were eligible, of whom 166 had not undergone colectomy, 46 had undergone subtotal colectomy with ileorectal anastomosis, and 10 had undergone partial resection of the large intestine. During the intervention period, five patients (2.3 %, 95 % confidence interval [CI] 0.74 %-5.18 %) underwent colectomy, and three patients died. Completion of the 5-year intervention period without colectomy was confirmed in 150 /166 patients who had not undergone colectomy (90.4 %, 95 %CI 84.8 %-94.4 %) and in 47 /56 patients who had previously undergone colectomy (83.9 %, 95 %CI 71.7 %-92.4 %).

CONCLUSION

IDP in patients with mild-to-moderate FAP could have the potential to be a useful means of preventing colorectal cancer without implementing colectomy. However, if the IDP protocol was proposed during a much longer term, it may not preclude the possibility that a large proportion of colectomies may still need to be performed.

Electrophysiological characteristics and catheter ablation of atypical fast-slow atrioventricular nodal reentrant tachycardia using an inferolateral left atrial slow pathway

Background

Understandings of subtypes of atypical atrioventricular nodal reentrant tachycardia (AVNRT) using variants of slow pathway (SP) are still growing. Inferolateral (inf-lat-) left atrial (LA) SP is a rare variant extending into an inf-lat-LA along the mitral annulus (MA).

Purpose

To characterize an unknown subtype of atypical fast-slow (F/S-) AVNRT using an inf-lat-LA-SP as a retrograde limb (inf-lat-LA-F/S-AVNRT).

Methods

This Japanese multicenter retrospective study enrolled 4 patients of inf-lat-LA-F/S-AVNRT that was characterized by the earliest site of atrial activation during tachycardia (EAA) between 3 and 6 o'clock along the MA. The diagnosis was made by an exclusion of AV reentrant tachycardia (AVRT) and atrial tachycardia (AT) according to the standard criteria and was confirmed by successful elimination of tachycardia and the inf-lat-LA-SP.

Results

Surface ECG during tachycardia revealed long RP appearance except one who had short RP due to a short conduction time across the inf-lat-LA-SP. During tachycardia, far-field LA activation preceding near-field activation of coronary sinus (CS) musculature was visible in the CS recording in 2. Retrograde conduction via the inf-lat-LA-SP with a decremental delay was consistently reproducible with ventricular stimulation in 2, 1 of whom had double atrial response, while it was always masked by the presence of a retrograde conduction via the fast pathway in 1 and a retrograde block at the lower common pathway in 1. An injection of a small dose of ATP transiently interrupted a retrograde conduction over the inf-lat-LA-SP, suggesting its ATP-sensitivity. Exclusion of AVRT was made by no resetting of tachycardia with left ventricular extrastimulus in 2 and VA dissociation during overdrive pacing of tachycardia in remaining 2. Exclusion of AT was made by V-A-V response after ventricular entrainment in 1 and termination without atrial capture by ventricular pacing in 2. Ablation of the right-sided SP was unsuccessful to eliminate the tachycardia, but ablation at or near the EAA by transseptal approach was successful to cure the tachycardia, associated with an elimination of a retrograde conduction over the inf-lat-LA-SP following a development of an accelerated junction rhythm in all. Low-frequency potentials preceding local atrial activation, consistent with a retrograde activation via the inf-lat-LA-SP were detected along the MA medial to the EAA in 1.

Conclusions

Differential diagnosis of tachycardia with the EAA in the inf-lat-LA and especially long RP appearance should include inf-lat-LA-F/S-AVNRT. Presumed arrhythmogenic substrate of the inf-lat-LA-SP seemed to be consistent with the remnant of embryogenic AV ring tissue in the electropharmacological and locational characteristics. Successful elimination of this AVNRT can be obtained by ablation of the inf-lat-LA-SP, but not of the right-sided SP.

Funding Acknowledgement

Type of funding sources: None.

Detection of BRCA1 Pathogenic Variant in a 24-Year-Old Endometrial Cancer Patient: Risks of Several Hereditary Tumor Syndromes Assessed Using Germline Multigene Panel Testing

A 24-year-old woman suspected of Lynch syndrome was found to carry a BRCA1 pathogenic variant, based on germline multigene panel testing (MGPT). The patient was diagnosed with endometrial carcinoma and underwent modified radical hysterectomy, bilateral salpingo-oophorectomy, pelvic lymphadenectomy, and omentectomy at the age of 23. Based on her father's history of colorectal cancer and her history of early onset endometrial cancer, mismatch repair protein immunohistochemistry analysis was performed. However, no loss of expression for mismatch repair proteins was found. Given her family history of ovarian and breast cancers, MGPT was recommended to identify the presence of any hereditary tumor syndromes. This testing revealed a BRCA1 pathogenic variant (exon13: c.1016delA, p.Lys339ArgfsX2) and diagnosed as hereditary breast and ovarian cancer syndrome (HBOC). Subsequently, the patient's mother also underwent single-site analysis for this variant, and the same pathogenic variant was detected. The patient and her mother are at high risk of developing BRCA1-associated HBOC-related cancers. Based on family history, clinical surveillance is currently underway for this patient and her mother. Currently, MGPT offers the potential for comprehensive genetic cancer risk assessment and may provide a more rational approach for the genetic assessment of those individuals whose personal and family cancer histories do not fit neatly into a single syndrome. This case suggests that if a patient is at high risk for hereditary tumor syndromes, MGPT should be considered to improve disease management strategies in clinical settings.

Endoscopic features of colorectal lymphoma according to histological type

Background and Aim

This study aimed to investigate the relationship between the histological type of colorectal lymphoma and its endoscopic features.

Methods

We retrospectively analyzed patients with primary colorectal lymphoma who were diagnosed using colonoscopy and biopsy specimens at the National Cancer Center Hospital, Tokyo, Japan. The lesions were macroscopically classified into the following types via colonoscopy: polypoid, ulcerative, multiple lymphomatous polyposis, diffuse, and mixed.

Results

A total of 117 lesions were identified in 90 patients enrolled in this study. Of these, 59 (50%) were located in the ileocecal region, 23 (20%) in the rectum, 9 (8%) in the transverse colon, 8 (7%) in the sigmoid colon, 7 (6%) in the descending colon, and 4 (3%) in the ascending colon. Moreover, the most common histological subtypes were diffuse large B‐cell lymphoma (DLBCL) in 39 patients (43%) and mantle cell lymphoma (MCL) in 23 patients (26%), followed by follicular lymphoma (FL; 17%), mucosa‐associated lymphoid tissue (MALT) lymphoma (9%), peripheral T‐cell lymphoma‐NOS (2%), monomorphic epitheliotropic intestinal T‐cell lymphoma (MEITL; 2%), and Burkitt lymphoma (1%). More than half of the DLBCL (52%), MCL (52%), and MALT (56%) lymphomas were macroscopically classified as polypoid types. In contrast, FL lesions showed various macroscopic types. The majority of DLBCL (62%) and FL (78%) lesions were distributed in the ileocecal region. MCL lesions tended to be widely spread in various sites of the large intestine.

Conclusions

Colorectal lymphomas showed macroscopically distinctive features depending on the histological type. Understanding the macroscopic classification of the lesions by colonoscopy and its distribution may be helpful in diagnosing the type of lymphoma and determining the malignant grade based on the histological types.

VULCANIZATION FOR REINFORCEMENT OF RUBBER

Sulfur cross-linking reagents play critical roles not only in cross-linking rubber chains but also in controlling network morphology for reinforcement of rubber. Zinc oxide (ZnO) is clearly discovered as the main component for both roles. Especially, the importance of network inhomogeneity, which is significantly governed by the dispersion of ZnO particles, is emphasized for reinforcing rubber materials. Specifically, the formation of network domains and their continuous structures is discussed by combining the mechanical properties of the vulcanizates from the viewpoint of the reinforcement effect of rubber. Two continuous structures of network domains are termed as the network-domain cluster and network-domain network, which are observed by atomic force microscopy. The ZnO particles play a role as template for the formation of the continuous structures of network domains. The findings provide us with a practical hint for producing high-performance rubber materials.

Intracrine activity involving NAD-dependent circadian steroidogenic activity governs age-associated meibomian gland dysfunction

Canonically, hormones are produced in the endocrine organs and delivered to target tissues. However, for steroids, the concept of tissue intracrinology, whereby hormones are produced in the tissues where they exert their effect without release into circulation, has been proposed, but its role in physiology/disease remains unclear. The meibomian glands in the eyelids produce oil to prevent tear evaporation, which reduces with aging. Here, we demonstrate that (re)activation of local intracrine activity through nicotinamide adenine dinucleotide (NAD⁺)-dependent circadian 3β-hydroxyl-steroid dehydrogenase (3β-HSD) activity ameliorates age-associated meibomian gland dysfunction and accompanying evaporative dry eye disease. Genetic ablation of 3β-HSD nullified local steroidogenesis and led to atrophy of the meibomian gland. Conversely, reactivation of 3β-HSD activity by boosting its coenzyme NAD⁺ availability improved glandular cell proliferation and alleviated the dry eye disease phenotype. Both women and men express 3β-HSD in the meibomian gland. Enhancing local steroidogenesis may help combat age-associated meibomian gland dysfunction.

Japan Society of Clinical Oncology Clinical Practice Guidelines 2017 for fertility preservation in childhood, adolescent, and young adult cancer patients: part 2

The Japan Society of Clinical Oncology (JSCO) published the "JSCO Clinical Practice Guidelines 2017 for Fertility Preservation in Childhood, Adolescent, and Young Adult Cancer Patients" in 2017. This was the first guideline in cancer reproductive medicine in Japan. In the field of cancer reproductive medicine, close cooperation between an oncologist and a physician for reproductive medicine is important from before treatment initiation until long after treatment. The guideline takes into consideration disease specificity and provides opinions from the perspective of oncologists and specialists in reproductive medicine that are in line with the current state of the Japanese medical system. It is intended to serve as a reference for medical staff in both fields regarding the availability of fertility preservation therapy before the start of cancer treatment. Appropriate use of this guideline makes it easier to determine whether fertility preservation therapy is feasible and, ultimately, to improve survivorship in childhood, adolescent, and young adult cancer patients. In this article (Part 2), we describe details by organ/system and also for pediatric cancer.

Japan Society of Clinical Oncology Clinical Practice Guidelines 2017 for fertility preservation in childhood, adolescent, and young adult cancer patients: part 1

In 2017, the Japan Society of Clinical Oncology (JSCO) published the JSCO Clinical Practice Guidelines 2017 for Fertility Preservation in Childhood, Adolescent, and Young Adult Cancer Patients. These were the first Japanese guidelines to address issues of oncofertility. In this field of medicine, sustained close cooperation between oncologists and reproductive specialists is essential from the diagnosis of cancer until many years after completion of cancer treatment. These JSCO guidelines were intended to guide multidisciplinary medical staff in considering the availability of fertility preservation options and to help them decide whether to provide fertility preservation to childhood, adolescent, and young adult cancer patients before treatment starts, with the ultimate goal of improving patient survivorship. The guidelines are presented as Parts 1 and 2. This article (Part 1) summarizes the goals of the guidelines and the methods used to develop them and provides an overview of fertility preservation across all oncology areas. It includes general remarks on the basic concepts surrounding fertility preservation and explanations of the impacts of cancer treatment on gonadal function by sex and treatment modality and of the options for protecting/preserving gonadal function and makes recommendations based on 4 clinical questions. Part 2 of these guidelines provides specific recommendations on fertility preservation in 8 types of cancer (gynecologic, breast, urologic, pediatric, hematologic, bone and soft tissue, brain, and digestive).

Evaluation of augmented-reality based navigation for brain tumor surgery

To date, several researchers have introduced augmented reality navigation (ARN) into neurological surgery. While its application in brain tumor surgery seems promising, reports on its utility have been limited, thus warranting further evaluation. To clarify the stages and approaches in which ARN is useful and assess the effect of presurgical discussion with surgeons, we assessed usefulness using a hand-held ARN system we had developed, which displays three-dimensional (3D) virtual structures overlaid on a real-time image of the surgical field via a tablet PC monitor. The system was tested in 20 patients undergoing various procedures, with the first 10 consecutive cases being unselected and the following 10 cases being selected, for whom 3D models were prepared per the surgeons' request. Thereafter, the surgeons ranked its usefulness during each stage of surgery. Consequently, case selection and presurgical discussions with surgeons considerably improved the usefulness, with the "useful" gradings improving from 50% to 88% across all surgical stages. Accordingly, usefulness improved from 50% to 90%, 67% to 100%, and 40% to 80% during the skin incision and craniotomy, dura incision, and intradural procedure stages, respectively. ARN was useful for superficial tumor resection, but less so for deep-seated tumor resection, except when using the transcortical and interhemispheric approaches. In conclusion, a tablet-type ARN can be useful during skin incisions, craniotomy and dura incisions, superficial tumor resections, and transcortical and interhemispheric approaches for deep-seated tumors. Case selection and presurgical discussions with surgeons were essential for the efficacy of ARN.

Tear miRNA expression analysis reveals miR-203 as a potential regulator of corneal epithelial cells

Background

microRNAs (miRNAs) are small noncoding RNAs that negatively regulate gene expression. They are found within cells and in body fluids. Extracellular miRNAs have been shown to associate with the surrounding tissues. Therefore, we predicted that miRNAs in tears may contribute to regulate corneal epithelial cell function. However, information on the miRNA expression profile of tears is limited and the specific functions of tear miRNAs for corneal epithelial cells are still unknown. To study the role of tear miRNAs, we determined which miRNAs are highly expressed in tears and examined the involvement of miRNAs in corneal epithelial cell viability.

Methods

miRNAs extracted from monkey tears and sera were subjected to microarray analysis. miRNAs of which expression levels were higher in tears than in sera were selected, and their expression levels were quantified by quantitative polymerase chain reaction (qPCR). To examine miRNA function, mimics and inhibitors of miRNAs were transfected into human corneal epithelial (HCE-T) cells and incubated for 24 or 48 h. After transfection of miRNA mimics and inhibitors, the viability of HCE-T cells was measured using the water soluble tetrazolium salt (WST) assay, and microarray analysis and qPCR were performed using total RNA extracted from HCE-T cells. siRNAs of the candidate targets for miR-203 were transfected into HCE-T cells and the WST assay was performed. To determine a direct target gene for miR-203, a dual luciferase reporter assay was performed in HCE-T cells using a luciferase reporter plasmid containing 3′-UTR of human IGFBP5.

Results

Microarray and qPCR analyses showed that miR-184 and miR-203 were expressed significantly more highly in tears than in sera (165,542.8- and 567.8-fold, respectively, p < 0.05). Of these two miRNAs, transfection of a miR-203 mimic significantly reduced the viability of HCE-T cells (p < 0.05), while a miR-203 inhibitor significantly increased this viability (p < 0.05). miR-203 mimic downregulated insulin-like growth factor-binding protein 5 (IGFBP5) and nuclear casein kinase and cyclin-dependent kinase substrate 1 (NUCKS1), while miR-203 inhibitor upregulated these two genes. Transfection of IGFBP5-siRNA decreased the viability of HCE-T cells. miR-203 mimic significantly diminished the luciferase reporter activity.

Conclusions

In this study, we identified miRNAs that are highly expressed in tears, and the inhibition of miR-203 increases the viability of corneal epithelial cells. Our results suggest that miR-203 contributes to regulating the homeostasis of corneal epithelial cells.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-021-02141-9.

Fast-slow atrioventricular nodal reentrant tachycardia phenotype mimicking the slow-slow type

Background

Fast-slow (F/S-) atrioventricular (AV) nodal reentrant tachycardia (AVNRT) is characterized by a short atrio-His (AH) interval and the earliest site of atrial activation (EAA) in the proximal coronary sinus (EAA-CS), while slow-slow (S/S-) AVNRT presents a long AH interval and EAA-CS. Those intracardiac appearances are initial indicators for making a diagnosis.

Purpose

To identify an unknown phenotype of F/S-AVNRT.

Methods

Among 46 consecutive patients with F/S-AVNRT, 6 patients (1 man, age 59±9) had an apparent but not typical (pseudo-) S/S-AVNRT during an electrophysiologic study. In 2 patients, pseudo-S/S-AVNRT was clinically documented.

Results

In all 6 patients, the diagnosis of F/S-AVNRT was made by an exclusion of atrial tachycardia with findings of 1) a V-A-V response following ventricular entrainment or 2) termination without atrial capture by ventricular pacing, and an exclusion of AV reentrant tachycardia with a ventriculoatrial dissociation during an initial (so-called QRS transition) zone of ventricular entrainment. An initial A-A-V activation sequence on atrial induction of F/S-AVNRT observed in 1 patient and Wenckebach-type AV block during ongoing F/S-AVNRT developing in 3 patients suggested the presence of the lower common pathway (LCP). Like the typical S/S-AVNRT, pseudo-S/S-AVNRT was induced with atrial stimulation after a jump in the AH interval or double ventricular response. However, in all patients, the pseudo-S/S-AVNRT transited to F/S-AVNRT following AV block in a single cycle and/or pseudo-S/S-AVNRT transited from spontaneously or triggered by atrial contractions. Importantly, on these transitions, the atrial cycle length (CL) and EAA-CS remained unchanged, that is, the atrial CL of S/S-AVNRT was almost identical to that of F/S-AVNRT, suggesting that the essential circuit of both tachycardias was identical. Actually, both tachycardias were cured by ablation at a single site in the traditional slow pathway (SP). Collectively, the pseudo-S/S-AVNRT was diagnosed as another phenotype of F/S-AVNRT accompanied by sustained antegrade conduction via another bystander (likely the left-sided or superior) SP breaking through the His bundle owing to the repetitive antegrade block at the LCP occurring by linking phenomenon, thus representing a long AH interval during the ongoing F/S-AVNRT. When the antegrade conduction is blocked at the bystander SP during the pseudo-S/S-AVNRT, releasing the linking phenomenon, the subsequent antegrade conduction reach the His-bundle via the fast pathway, thus returning to F/S-AVNRT.

Conclusions

An unknown, but not rare F/S-AVNRT phenotype exists that apparently mimics the typical S/S-AVNRT and is also an unknown subtype of apparent S/S-AVNRT. The presence of this pseudo-S/S-AVNRT suggests the limitation of classifying types of AVNRT based on AH and HA intervals during tachycardia. Understandings of this phenotype can advance a diagnosis of atypical AVNRT with multiple phenotypes.

Funding Acknowledgement

Type of funding sources: None.

Association of the extent of myocardial ischemia with outcomes in patients with suspected coronary artery disease in Japan: a cohort study

Background

There is an ongoing controversy regarding the necessity of single-photon emission computed tomography (SPECT) for patients with ischemic heart diseases after the publication of the results of the ISCHEMIA trial.

Purpose

We aimed to evaluate the association of the extent of myocardial ischemia with outcomes in patients with suspected coronary artery disease in Japan.

Methods

From the data of 2780 patients with stable angina who were enrolled prospectively between January 2006 and March 2008 in Japan and had undergone physician-referred non-invasive imaging tests, 1205 patients managed with SPECT were stratified by 10% myocardial ischemia. Major adverse cardiac events (MACEs), including death, myocardial infarction, hospitalization for heart failure, and late revascularization, were followed-up for 1 year.

Results

Patients with ≥10% myocardial ischemia (n=173) were older than patients with &lt;10% myocardial ischemia (n=1032) and had a significantly higher 1-year cumulative incidence of MACEs (9.1% vs. 1.2%, P&lt;0.0001). After adjusting for confounders, the risk of ≥10% myocardial ischemia relative to &lt;10% myocardial ischemia for MACEs remained significant (adjusted hazard ratio [95% confidence interval], 2.40 [1.09–5.26], P=0.029).

Conclusion

The presence of ≥10% myocardial ischemia was significantly associated with the 1-year risk for MACEs in Japanese patients with suspected coronary artery disease.

Funding Acknowledgement

Type of funding sources: None. Study flowchartOutcomes

Empagliflozin improves prognosis and energetic properties through modulating mitochondrial function in failing murine hearts

Background/Introduction

Sodium-glucose cotransporter 2 (SGLT2) inhibitors have been reported to have beneficial effects on heart failure in large clinical trials; however, the underlying mechanism is still unclear.

Purpose

The purpose of this study is to elucidate the mechanism of cardioprotective effect of empagliflozin in heart failure.

Methods

Eight-week-old mice deficient in cardiac and skeletal muscle-specific manganese superoxide dismutase, a mouse model of dilated cardiomyopathy (MnSOD-cKO mice), were given food mixed with or without 10 mg/kg empagliflozin for seven weeks and evaluated. Mitochondrial function in the cardiac muscle were measured by a high-resolution respirometer, Oxygraph-2K. Respiratory gas analysis were performed by indirect calorimetry (ARCO 2000) to estimate the energy consumption and energetic substrates.

Results

The survival rate (P=0.015) and cardiac fibrosis (P=0.036) were significantly improved in the empagliflozin group. The capacity of oxidative phosphorylation in cardiac mitochondria was significantly improved by empagliflozin. Blood lactate levels were decreased in the empagliflozin group, indicating that energy such as ATP could be produced without resorting to anaerobic metabolism.

Respiratory gas analysis revealed significant improvement in energy expenditure along with increase in food intake. Respiratory quotient was not different between the two groups, showing the consumption of the carbohydrate to fat rate was not changed by empagliflozin in this study. Ketone levels in blood and HbA1c were neither significantly different between the two groups. Although a moderate amount glucose was excreted in urine in the empagliflozin group (128.3±20.4 mg/day, 0.51±0.08 kcal/day), the available energy substrates in the whole body nonetheless expanded because of the increased caloric intake (10.58±0.72 in control group vs. 13.55±0.08 kcal/day in empagliflozin group, P=0.018).

Conclusion(s)

We have shown that empagliflozin improved myocardial mitochondrial function and increased energy metabolism, which was accompanied by adequate energy intake and uptake, even in heart failure. Empagliflozin decreased myocardial fibrosis and improved prognosis in failing murine hearts through positive energetical properties including mitochondrial function. The finding that empagliflozin modulates cardiac metabolism in a positive way provides a novel mechanism for the cardioprotective effect of SGLT2 inhibitors in heart failure.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Boehringer Ingelheim Empa improved prognosis in HFEmpa improved mitochondrial function

Gene therapy in the putamen for curing AADC deficiency and Parkinson's disease

This commentary provides an overview of the putamen as an established target site for gene therapy in treating aromatic l‐amino acid decarboxylase (AADC) deficiency and Parkinson’s disease, two debilitating neurological disorders that involve motor dysfunction caused by dopamine deficiencies. The neuroanatomy and the function of the putamen in motor control provide good rationales for targeting this brain structure. Additionally, the efficacy and safety of intraputaminal gene therapy demonstrate that restoration of dopamine synthesis in the putamen by using low doses of adeno‐associated viral vector serotype 2 to deliver the hAADC gene is well tolerated. This restoration leads to sustained improvements in motor and nonmotor symptoms of AADC deficiency and improved uptake and conversion of exogenous l‐DOPA into dopamine in Parkinson’s patients.

Clinical and pathological outcomes of risk-reducing salpingo-oophorectomy for Japanese women with hereditary breast and ovarian cancer

BACKGROUND

To clarify the clinical as well as pathological outcomes in Japanese women with germline pathogenic BRCA1/2 variants who underwent risk-reducing salpingo-oophorectomy (RRSO).

METHODS

This prospective study examined the rate of occult cancer and primary peritoneal cancer after RRSO at our institution in the period from 2011 to 2020. Clinical records of genetically confirmed patients with germline pathogenic BRCA1/2 variants who desired to undergo RRSO were reviewed. Specimens obtained during RRSO were pathologically diagnosed as per SEE-FIM protocol. All the participants underwent magnetic resonance imaging (MRI) about 1 month preoperatively.

RESULTS

One hundred and seventeen women underwent RRSO during this period. Of these, the numbers of women with germline pathogenic BRCA1 and BRCA2 variants were 72 and 45, respectively. The mean observational time after RRSO was 35.8 months. Despite negative preoperative screening results, three (2.6%) serous tubal intraepithelial carcinoma and three (2.6%) invasive carcinomas were identified. Of the three invasive carcinomas cases, two were International Federation of Gynecology and Obstetrics (FIGO) stage I primary fallopian tube cancer, and the third case was double cancer (ovarian cancer and fallopian tube cancer) with FIGO stage IC3.

CONCLUSIONS

The rate of occult neoplasms was similar to those reported by studies performed in other countries. Although women with occult cancer were diagnosed with FIGO stage I, the MRI performed 1 month preoperatively did not show any such malignant findings. Thus, RRSO is the only promising method that can improve the prognosis in women with germline pathogenic BRCA1/2 variants.

Dopaminergic restoration of prefrontal cortico-putaminal network in gene therapy for aromatic l-amino acid decarboxylase deficiency

Aromatic l-amino acid decarboxylase (AADC) is an essential dopamine-synthesizing enzyme. In children with AADC deficiency, the gene delivery of AADC into the putamen, which functionally interacts with cortical regions, was found to improve motor function and ameliorate dystonia. However, how the restoration of dopamine in the putamen in association with cortico-putaminal networks leads to therapeutic effects remains unclear. Here, we examined neuroimaging data of eight patients with AADC deficiency (five males and three females, age range 4-19 years) who received the AADC gene therapy of the bilateral putamen in an open-label phase 1/2 study. Using high-resolution positron emission tomography with a specific AADC tracer, 6-[¹⁸F]fluoro-l-m-tyrosine (FMT), we showed that FMT uptake increased in the broad area of the putamen over the years. Then, with the structural connectivity-based parcellation of the putaminal area, we found that motor improvement is associated with dopaminergic restoration of the putaminal area that belongs to the prefrontal cortico-putaminal network. The prefrontal area dominantly belongs to the frontoparietal control network, which contributes to cognitive-motor control function, including motor initiation and planning. The results suggest that putaminal dopamine promotes the development of an immature motor control system, particularly in the human prefrontal cortex that is primarily affected by AADC deficiency.

Preparation and Readout of Multielectron High-Spin States in a Gate-Defined GaAs/AlGaAs Quantum Dot

We report the preparation and readout of multielectron high-spin states, a three-electron quartet, and a four-electron quintet, in a gate-defined GaAs/AlGaAs single quantum dot using spin filtering by quantum Hall edge states coupled to the dot. The readout scheme consists of mapping from multielectron to two-electron spin states and a subsequent two-electron spin readout, thus obviating the need to resolve dense multielectron energy levels. Using this technique, we measure the relaxations of the high-spin states and find them to be an order of magnitude faster than those of low-spin states. Numerical calculations of spin relaxation rates using the exact diagonalization method agree with the experiment. The technique developed here offers a new tool for the study and application of high-spin states in quantum dots.

Spontaneous Regression of Mismatch Repair-Deficient Colon Cancer: A Case Series

Spontaneous regression of cancer is a rare phenomenon, with 33 colorectal cancer cases reported between 1900 and 2020.^1-4 Spontaneous regression is defined as the partial or complete disappearance of a tumor without treatment.^1,3 Several factors may be involved in this process, including biopsy, mechanical stress, humoral factors, and infection.^1,5 However, no concrete evidence for the mechanistic insights has been indicated.

Through-Space Charge Transfer in Copper Coordination Networks with Copper-Halide Guest Anions

We prepared coordination networks that show relatively strong emission with through-space charge-transfer (TSCT) transitions. Thermolysis of a kinetically assembled network with Cu₂Br₂ dimer connectors, which was assembled from a CuBr cluster and the T_d ligand 4-4-tetrapyridyltetraphenylmethane (4-TPPM), generated a highly luminescent network composed of Cu⁺ connectors and 4-TPPM linkers with CuBr₂^- guests. We clarified that the electronic transitions in this network include TSCT in addition to the typical metal-ligand charge transfer (MLCT) observed in conventional Cu complexes.

Efficacy of Full-Spectrum Endoscopy to Visualize the Major Duodenal Papilla in Patients with Familial Adenomatous Polyposis

BACKGROUND AND AIMS

Duodenal cancer is one of the extracolonic malignancies with known mortality in familial adenomatous polyposis (FAP) patients. Visualization of the major duodenal papilla (MDP) with a standard esophagogastroduodenoscopy (EGD) is currently insufficient because of the limited field of view. Full-spectrum endoscopy (FUSE), utilizing double imagers located on the front and side of the endoscopic tip, provides a wider field of view up to 245 degrees. The aim of this study was to evaluate the efficacy of FUSE in visualizing MDP in patients with FAP.

METHODS

This study was a single-center retrospective study including 49 FAP patients undergoing surveillance at our institution. EGD was performed by qualified endoscopists using FUSE, and visibility of the MDP was evaluated. All examinations were video-recorded, and the clips for individual patient were edited to forward view images alone (conventional group) and 2-view images of the duodenum (forward and side-view [FUSE group]). Three other qualified external endoscopists independently reviewed the videos and compared the visibility of MDP between the conventional and the FUSE groups. Primary endpoint was the rate of Type 1 visibility (whole area of the papilla) in off-site video reviews. We also assessed MDP visibility on-site as secondary endpoint.

RESULTS

The rate of type 1 MDP visibility was significantly higher in the FUSE group than conventional group in both on-site (32.6/100%, p < 0.001) and off-site reviews (8.2, 16.3, 14.3/100, 98, and 100%, p < 0.001).

CONCLUSIONS

FUSE is recommended in screening and surveillance EGD to better visualize MDP in FAP patients.

POS1487-HPR NEXT-GENERATION ONLINE TELEMEDICINE SYSTEM UTILIZING MIXED REALITY FOR RHEUMATOID ARTHRITIS

Background:

Telemedicine can be performed using a conventional videophone or web conferencing system. Then, joint lesions can only be observed and inferred from two-dimensional images, and it is difficult to perform accurate joint assessments, which is essential for the management of rheumatoid arthritis (RA).

Objectives:

To develop the next-generation online telemedicine system utilizing mixed reality for RA.

Methods:

We have developed a system that can assess joints accurately in three-dimensions images in real-time, using Azure Kinect DK (depth sensor)/ HoloLens 2 (headset), which are mixed reality technologies, and Teams (online interview/chat) provided by Microsoft. Furthermore, by applying artificial intelligence (AI), we plan to implement additionally to this system 1) a function to quickly catch and automatically evaluate the patient’s anxiety and changes in facial expressions at the time of examination, 2) a function to record dialogue with the patient in chronological order, 3) a function to support the detection of swollen joints, and 4) function to automatically analyze the questionnaire.

Results:

This system remotely connects a rheumatologist in the Nagasaki University Hospital (Nagasaki City, urban area) and a patient with RA and a non- rheumatologist in the Goto Central Hospital (Goto Island, rural area). A three-dimensional hologram of the patient’s hand projected in front of a rheumatologist. Using this system, we are able to evaluate joints more accurately than using a conventional videophone or web conferencing system.

Conclusion:

It is expected that this system will enable remote medical care specializing in rheumatology, which is standardized at a high level even in areas without rheumatologists such as remote islands and remote areas. This system remotely connects Nagasaki City and Goto Island, but due to the performance of the system, it is not limited to these areas and it is possible to connect rheumatologists to any area that can be connected to the network. It is also effective for the purpose of avoiding the risk of infection during long-distance hospital visits under the epidemic of COVID-19 infection.

References:

[1]Mov Disord. 2020;35:1719-1720.

Disclosure of Interests:

Shin-ya Kawashiri Speakers bureau: Speaker fees from AbbVie, Asahi Kasei, Astellas, Chugai, Eisai, Eli Lilly, Mitsubishi Tanabe, Novartis, and ONO., Grant/research support from: Research grants from Pfizer., Fumiaki Nonaka: None declared, Shinji Chiba: None declared, Tomoyuki Honda: None declared, Tomohiko Nakajima: None declared, Tomoyuki Ishikawa: None declared, Atsushi Kawakami Speakers bureau: Speaker fees from AbbVie, Actelion, Asahi Kasei, Astellas, Boehringer Ingelheim, Celltrion, Chugai, Daiichi Sankyo, Eisai, Eli Lilly, GSK, Janssen, Kowa, MedPeer, Mitsubishi Tanabe, Novartis, ONO, Pfizer, Taisho, and Takeda., Grant/research support from: Grants and research support from AbbVie, Actelion, Asahi Kasei, Astellas, AYUMI, Boehringer Ingelheim, Bristol-Myers Squibb, Celltrion, Chugai, Daiichi Sankyo, Eisai, Eli Lilly, Kyowa Hakko Kirin, MSD, Neopharma, Novartis, ONO, Sanofi, Taisho, Takeda Science Foundation, and Teijin

Intra-cisterna magna delivery of an AAV vector with the GLUT1 promoter in a pig recapitulates the physiological expression of SLC2A1

Glucose transporter 1 deficiency syndrome (GLUT1DS) is caused by haplo-insufficiency of SLC2A1, which encodes GLUT1, resulting in impaired hexose transport into the brain. Previously, we generated a tyrosine-mutant AAV9/3 vector in which SLC2A1 was expressed under the control of the endogenous GLUT1 promoter (AAV-GLUT1), and confirmed the improved motor function and cerebrospinal fluid glucose levels of Glut1-deficient mice after cerebroventricular injection of AAV-GLUT1. In preparation for clinical application, we examined the expression of transgenes after intra-cisterna magna injection of AAV-GFP (tyrosine-mutant AAV9/3-GFP with the CMV promoter) and AAV-GLUT1. We injected AAV-GFP or AAV-GLUT1 (1.63 × 10¹² vector genomes/kg) into the cisterna magna of pigs to compare differential promoter activity. After AAV-GFP injection, exogenous GFP was expressed in broad areas of the brain and peripheral organs. After AAV-GLUT1 injection, exogenous GLUT1 was expressed predominantly in the brain. At the cellular level, exogenous GLUT1 was mainly expressed in the endothelium, followed by glia and neurons, which was contrasted with the neuronal-predominant expression of GFP by the CMV promotor. We consider intra-cisterna magna injection of AAV-GLUT1 to be a feasible approach for gene therapy of GLUT1DS.

Malignant potential of colorectal neoplasms in Lynch syndrome: an analysis of 325 lesions endoscopically treated at a single institute

BACKGROUND

Patients with Lynch syndrome are at an increased risk of developing colorectal cancer, and the adenoma-carcinoma sequence is accelerated in these patients. However, the clinicopathological characteristics of colorectal neoplasms in Lynch syndrome patients are not well-known.

METHODS

A total of 325 consecutive colorectal neoplasms were endoscopically removed from 68 patients with Lynch syndrome between June 2005 and May 2018 and retrospectively reviewed.

RESULTS

Of the 325 lesions, 94 (29%), 220 (68%) and 11 (3%) were from patients with MLH1, MSH2 and MSH6 mutations, respectively. The median lesion size was 5 mm (range 2-40 mm), with 229 (71%) lesions having a non-polypoid morphology. The frequencies of advanced neoplasms, including high-grade adenomas, intramucosal carcinomas and submucosal invasive carcinomas were 14, 34, 97 and 93% for lesions with diameters of <5, ≥5 and <10, ≥10 and <20, and ≥20 mm, respectively. The frequencies of advanced neoplasms in the proximal colon, distal colon and rectum did not significantly differ (36, 35 and 41%, respectively).

CONCLUSIONS

Our results suggest that the malignant transformation interval from low-grade adenomas to advanced neoplasms is similar in all parts of the colon. Furthermore, since one-third of neoplastic lesions with diameters of ≥5 and <10 mm and most of those ≥10 mm were advanced neoplasms, we recommend that in Lynch syndrome patients, careful colonoscopic surveillance should be performed throughout the colon, and all neoplastic lesions, regardless of the size, should be subjected to detailed endoscopic examination, complete resection and detailed pathological examination.

Chemoprevention with low-dose aspirin, mesalazine, or both in patients with familial adenomatous polyposis without previous colectomy (J-FAPP Study IV): a multicentre, double-blind, randomised, two-by-two factorial design trial

BACKGROUND

The only established treatment for preventing colorectal cancer in patients with familial adenomatous polyposis (FAP) is colectomy, which greatly reduces patient quality of life. Thus, an alternative method is warranted. In this trial, we aimed to clarify the individual and joint effects of low-dose aspirin and mesalazine on the recurrence of colorectal polyps in Japanese patients with FAP.

METHODS

This was a randomised, double-blind, placebo-controlled, multicentre trial with a two-by-two factorial design done in 11 centres in Japan. Eligible patients were aged 16-70 years and had a history of more than 100 adenomatous polyps in the large intestine, without a history of colectomy. Before the study, patients underwent endoscopic removal of all colorectal polyps of at least 5·0 mm in diameter. Randomisation was done with a minimisation method with a random component to balance the groups with respect to the adjustment factors of sex, age (<30 years vs ≥30 years), or smoking status at the time of entry. Patients and researchers were masked to the treatment group. There were four groups: aspirin (100 mg per day) plus mesalazine (2 g per day), aspirin (100 mg per day) plus mesalazine placebo, aspirin placebo plus mesalazine (2 g per day), or aspirin placebo plus mesalazine placebo. Treatment was continued until 1 week before 8 month colonoscopy. The primary endpoint was the incidence of colorectal polyps of at least 5·0 mm at 8 months and was assessed in the intention-to-treat population. Safety was assessed in the ITT population. We also did a per-protocol analysis including only patients who took at least 70% of the allocated study drug. This trial is registered with the UMIN Clinical Trials Registry, number UMIN000018736, and is complete.

FINDINGS

Between Sept 25, 2015, and March 13, 2017, 104 patients were randomly assigned to receive either aspirin or aspirin placebo (n=52) or mesalazine or mesalazine placebo (n=52). Two patients withdrew from the aspirin plus mesalazine placebo group. 26 (50%) of 52 patients who received no aspirin had colorectal polyps of at least 5·0 mm at 8 months, as did 15 (30%) of the 50 patients who received any aspirin, 21 (42%) of the 50 patients who received no mesalazine, and 20 (38%) of the 52 patients who received any mesalazine. The adjusted odds ratio for polyp recurrence was 0·37 (95% CI 0·16-0·86) in the patients who received any aspirin and 0·87 (95% CI 0·38-2·00) in any who received mesalazine. The most common adverse events were grade 1-2 upper gastrointestinal symptoms in three (12%) of 26 patients who received aspirin plus mesalazine, one (4%) of 24 patients who received aspirin plus mesalazine placebo, and one (4%) of 26 patients who received mesalazine plus aspirin placebo. There was one grade 4 event in the mesalazine plus aspirin placebo group, but not related to the treatment.

INTERPRETATION

Low-dose aspirin safely suppressed the recurrence of colorectal polyps larger than 5·0 mm in patients with FAP. These results suggest an effect of low-dose aspirin for FAP and could be an alternative method for preventing colorectal cancer in FAP.

FUNDING

Japan Agency for Medical Research and Development.