Bridging genomics and phenomics of gastric carcinoma

Genetic alterations are the starting point leading to numerous changes in clinical and pathologic features (phenotypes) of individual cancers; however, their inter-relationships in gastric cancers (GC) are unclear. We performed massive parallel sequencing of 381 cancer-related genes and compared the results with clinical and pathologic findings in 330 GC. High tumor mutation burden (TMB) accounted for 11% of GC (n = 37) and all 19 MSI-H GCs were high TMB. High TMB was significantly more frequent in intestinal-type by Lauren, tumor with higher host cellular immune response, earlier AJCC stage and favorable prognosis. The most significantly mutated genes were TP53 (54%), ARID1A (23%), CDH1 (22%), PIK3CA (12%), RNF43 (10%) and KRAS (9%). For receptor tyrosine kinases, amplifications detected by immunohistochemistry were higher than sequencing (HER2, 9.1% vs. 5.8%; EGFR, 11.2% vs. 6.1%; FGFR2, 4.6% vs. 3.9%, c-MET, 3.4% vs. 0.9%). PTEN protein loss (22%) correlated well with underlying PTEN alterations while ATM loss (27%) was not significantly correlated with genetic alterations of ATM. p53 protein expression predicted alterations of TP53 with high sensitivity (97.8%) and low (15.9%) specificity. The poorly cohesive histology/CDH1-mutant GC subgroup showed the worst survival (p < 0.001). PD-L1 expression was significantly associated with MSI-H, MLH1 loss, ATM loss, MET positivity, higher host immune response, and genetic alterations of ARID1A, BRD3, PIK3CA, KRAS, MAP3K13, CDH2, PTEN and ESR1. The merged clinical, pathology and genomics of GC provide a better understanding of GC and new insights into the treatment of GC.

Clarification of glycosylphosphatidylinositol anchorage of OTOANCORIN and human OTOA variants associated with deafness

Otoancorin (OTOA), encoded by OTOA, is required for the development of the tectorial membrane in the inner ear. Mutations in this gene cause nonsyndromic hearing loss (DFNB22). The molecular mechanisms underlying most DFNB22 remain poorly understood. Disruption of glycosylphosphatidylinositol (GPI) anchorage has been assumed to be the pathophysiology mandating experimental validation. From a Korean deaf family, we identified two trans OTOA variants (c.1320 + 5 G > C and p.Gln589ArgfsX55 [NM_144672.3]) . The pathogenic potential of c.1320 + 5 G > C was confirmed by a minigene splicing assay. To experimentally determine the GPI anchorage, wild-type (WT) and mutant OTOA harboring p.Gln589ArgfsX55 were expressed in HEK293T cells. The mutant OTOA with p.Gln589ArgfsX55 resulted in an uncontrolled release of OTOA into the medium in contrast with phosphatidylinositol-specific phospholipase C-induced controlled release of WT OTOA from the cell surface. Together, the results of this reverse translational study confirmed GPI-anchorage of OTOA and showed that downstream sequences from the 589th amino acid are critical for GPI-anchorage.

A Spindle Cell Tumor of Unknown Origin and Diffuse Bone Marrow Involvement in a Patient with Hypercalcemia

Background

Metastasis of unknown origin in bone marrow is infrequent, although, when it occurs, adenocarcinoma is the most common histologic type. Involvement of bone marrow by a spindle cell tumor and presentation with hypercalcemia are very rare.

Method

This report describes a 21-year-old man with diffuse bone marrow involvement from a spindle cell tumor.

Results

The patient presented with low back pain, anemia, thrombocytopenia, azotemia, and hypercalcemia. Bone marrow biopsy revealed a spindle cell tumor that was positive for vimentin staining but whose primary site could not be identified. A bone marrow scan revealed absence of uptake, which suggested systemic disease. We treated this case as a type of sarcoma by giving combined chemotherapy consisting of vincristine, actinomycin-D and cyclophosphamide. The patient showed a clinical response for seven months, but the disease progressed despite chemotherapy and he died one year after diagnosis.

Conclusions

We have documented a rare case of spindle cell tumor involving bone marrow without evidence of the tumor's primary site.

Four distinct immune microenvironment subtypes in gastric adenocarcinoma with special reference to microsatellite instability

Introduction

Programmed death-ligand 1 (PD-L1) can be overexpressed in tumours other than Epstein-Barr virus (EBV)-positive (EBV⁺) or microsatellite instability-high (MSI-H) gastric cancer (GC) subtypes. We aimed to determine the tumour immune microenvironment (TME) classification of GC to better understand tumour-immune interactions and help patient selection for future immunotherapy with special reference to MSI-H.

Methods

Immunohistochemistry (IHC) for PD-L1 and CD8⁺ T cells in three distinct subtypes of GC (43 EBV⁺, 79 MSI-H and 125 EBV^-/MSS) were performed and analysed. In 66 MSI-H GC, mutation counts were compared with PD-L1 expression and survival of the patients.

Results

GC TME divided by PD-L1 IHC and tumour-infiltrating lymphocytes (TIL) measured by intratumoural CD8 density showed: (1) about 40% of GC are type I (PD-L1⁺/TIL⁺) consisting ~70% of MSI-H or EBV⁺ GC, and ~15% of EBV^-/microsatellite stable (MSS) GC patients show the best survival in both disease-free (HR 2.044) and overall survival (HR 1.993); this type would respond to a checkpoint blockade therapy; (2) almost 30% of GC are type II (PD-L1^-/TIL^-) with the worst survival; (3) approximately 10% of GC are type III (PD-L1⁺/TIL^-); and (4) up to 20% are type IV (PD-L1^-/TIL⁺) and, unexpectedly, ~25% of EBV⁺ or MSI-H GC are within this subtype. In MSI-H GC, frequent frameshift mutations were observed in ARID1A, RNF43, NF1, MSH6, BRD3, NCOA3, BCORL1, TNKS2 and NPM1 and the numbers of frameshift mutation correlated significantly with PD-L1 expression (P<0.05).

Discussion

GC can be classified into four TME types based on PD-L1 and TIL, and numbers of frameshift mutation correlate well with PD-L1 expression in MSI-H GC.

Comprehensive somatic genome alterations of urachal carcinoma

BACKGROUND

Urachal cancer is a rare cancer that develops in the urachus. Because of its rarity, standard treatment therapies for urachal cancer are not established, and chemotherapeutic regimens for bladder cancer have been unsuccessful for patients with urachal cancer. Hence, we aim to understand a systematic molecular characterisation of urachal cancer.

METHODS

We identified somatic single-nucleotide variations (SNVs)/indels and somatic copy number aberrations (SCNAs) in the 17 patients by using whole-exome sequencing (WES) and OncoScan platform (Affymetrix) as follows: tumour-normal paired sequencing (WES, n=10), tumour-only sequencing (WES, n=1; targeted deep sequencing, n=16), and OncoScan (n=17).

RESULTS

Our analyses identified 27 genes with somatic SNVs and indels, as well as six genes (APC, COL5A1, KIF26B, LRP1B, SMAD4 and TP53) that were recurrent in at least two patients. By analysing the SCNAs, we found that the extent of chromosomal amplification was highly associated with the patient's cancer stage. Interestingly, 35% (6/17) of the patients had focal DNA amplifications in fibroblast growth factor receptor family genes. The integration of somatic SNVs, indels and SCNAs revealed significant alterations in the mitogen-activated protein kinase signalling pathways.

CONCLUSIONS

Our genome-wide analysis of urachal cancer suggests that molecular characteristics may be important for the treatment of urachal cancer.

Vascular Structures of the Right Colon: Incidence and Variations with Their Clinical Implications

BACKGROUND AND AIMS

There is a demand for a better understanding of the vascular structures around the right colonic area. Although right hemicolectomy with the recent concept of meticulous lymph node dissection is a standardized procedure for malignant diseases among most surgeons, variations in the actual anatomical vascular are not well understood. The aim of the present review was to present a detailed overview of the vascular variation pertinent to the surgery for right colon cancer.

MATERIALS AND METHODS

Medical literature was searched for the articles highlighting the vascular variation relevant to the right colon cancer surgery.

RESULTS

Recently, there have been many detailed studies on applied surgical vascular anatomy based on cadaveric dissections, as well as radiological and intraoperative examinations to overcome misconceptions concerning the arterial supply and venous drainage to the right colon. Ileocolic artery and middle colic artery are consistently present in all patients arising from the superior mesenteric artery. Even though the ileocolic artery passes posterior to the superior mesenteric vein in most of the cases, in some cases courses anterior to the superior mesenteric artery. The right colic artery is inconsistently present ranging from 63% to 10% across different studies. Ileocolic vein and middle colic vein is always present, while the right colic vein is absent in 50% of patients. The gastrocolic trunk of Henle is present in 46%-100% patients across many studies with variation in the tributaries ranging from bipodal to tetrapodal. Commonly, it is found that the right colonic veins, including the right colic vein, middle colic vein, and superior right colic vein, share the confluence forming the gastrocolic trunk of Henle in a highly variable frequency and different forms.

CONCLUSION

Understanding the incidence and variations of the vascular anatomy of right side colon is of crucial importance. Failure to recognize the variation during surgery can result in troublesome bleeding especially during minimal invasive surgery.

Discrepancies of the Values on the Withholding Futile Interventions between Physician and Family Members of Terminal Cancer Patients

PURPOSE

To analyze the controversies surrounding therapeutic decision-making and the withholding of life- sustaining treatments, values held concerning therapeutic interventions of terminal cancer patients are compared between physicians and family members.

MATERIALS AND METHODS

42 advanced or terminal stage cancer patients were enrolled for the study. The questionnaires were administered to the duty doctor and the family of the patients. Questions included whether to use new agents with a 15% partial efficacy and whether to use opioid analgesics, intravenous nutrition, a feeding tube, antibiotics, and hemodialysis. Additionally, we asked about the administration of CPR, ventilator application, and euthanasia. If the family permitted, the same questionnaires were given to the patients.

RESULTS

Of the 42 cases, 5 families refused to answer the questionnaire. Of the available 37 families, only 5 families permitted access to the patients. Of the 5 patients, 2 patients refused the questionnaire. Only 67.6% and 8.1% of families and the patients clearly understood the stage of cancer. The use of a new agent was accepted by 45.2% of the physicians and 45.9% of the families. The rankings of the acceptance of treatment in the physicians and in the families were similar. The concordance rate between the physicians and the families was lowest on ventilator application and CPR. 31% of the physicians and 43.2% of the families agreed on the issue of euthanasia.

CONCLUSION

Values held on issues like therapeutic decision-making and the withholding of life-sustaining treatments in terminal cancer patients are discordant between physicians and family members. In order to resolve controversies on the role of physicians in end-of-life decisions, the values of physicians as well as patients and their family members should be considered in the final decision-making process.

Efficacy of Low-dose Paclitaxel and Cisplatin in Patients with Advanced Non-Small Cell Lung Cancer

PURPOSE

To evaluate the efficacy and toxicity of combination chemotherapy with low-dose paclitaxel and cisplatin in patients with advanced non-small cell lung cancer.

MATERIALS AND METHODS

Chemotherapy-naive patients with unresectable, pathologically proven non-small cell lung cancer were eligible for inclusion in the study. Patients received paclitaxel (145 mg/m2 iv 3 hour D1) and cisplatin (60 mg/m2 iv D1) every 3 weeks.

RESULTS

Forty-two patients were enrolled between February 2000 and February 2001. The median age was 53.5 years. Patients with adenocarcinoma numbered 29, squamous cell carcinoma 7, large cell carcinoma 3, and undifferentiated carcinoma 3. Seventeen patients had stage IIIB, 19 had stage IV disease and the remaining 6 displayed recurred disease after previous surgical resection. Four patients terminated treatment early because of hypersensitivity (1) and severe emesis (3). Of the 38 evaluable patients, 14 had PR and the response rate was 36.8%. Among partial responders, 6 patients received additional chest radiation. The median duration of response was 47.9 weeks and the median overall survival was 54.0 weeks. Of the total 176 courses, 14 were delayed, 22 required dose reduction, and grade 3~4 neutropenia occurred in 5.6% of courses. Only one episode of neutropenic fever developed and there were no treatment- related mortalities. Other toxicities were generally mild.

CONCLUSION

The combination chemotherapy with low-dose paclitaxel and cisplatin was effective and tolerable in patients with advanced non-small cell lung cancer.

Multicentre study of robotic intersphincteric resection for low rectal cancer

BACKGROUND

There is a lack of information regarding the oncological safety of robotic intersphincteric resection (ISR) with coloanal anastomosis. The objective of this study was to compare the long-term feasibility of robotic compared with laparoscopic ISR.

METHODS

Between January 2008 and May 2011, consecutive patients who underwent robotic or laparoscopic ISR with coloanal anastomosis from seven institutions were included. Propensity score analyses were performed to compare outcomes for groups in a 1 : 1 case-matched cohort. The primary endpoint was 3-year disease-free survival.

RESULTS

A total of 334 patients underwent ISR with coloanal anastomosis, of whom 212 matched patients (106 in each group) formed the cohort for analysis. The overall rate of conversion to open surgery was 0.9 per cent in the robotic ISR group and 1.9 per cent in the laparoscopic ISR group. Nine patients (8.5 per cent) in the laparoscopic group and three (2.8 per cent) in the robotic ISR group still had a stoma at last follow-up (P = 0.075). Total mean hospital costs were significantly higher for robotic ISR (€ 12,757 versus € 9223 for laparoscopic ISR; P = 0.037). Overall 3-year local recurrence rates were similar in the two groups (6.7 per cent for robotic and 5.7 per cent for laparoscopic resection; P = 0.935). The combined 3-year disease-free survival rates were 89.6 (95 per cent c.i. 84.1 to 95.9) and 90.5 (85.4 to 96.6) per cent respectively (P = 0.298).

CONCLUSION

Robotic ISR with coloanal anastomosis for rectal cancer has reasonable oncological outcomes, but is currently too expensive with no short-term advantages.

Comparison of miniplates and biodegradable plates in reconstruction of the mandible with a fibular free flap

Miniplates and reconstruction plates are usually used to fix a fibular free flap, the gold standard in reconstruction of large segmental mandibular defects. Though biodegradable plates are used in orthognathic operations and repair of fractures nowadays, we know of no studies of the use of biodegradable plates in the reconstruction of segmental mandibular defects including a fibular free flap. We retrospectively reviewed 47 patients who had reconstruction of segmental mandibular defects with fibular free flaps during the past 10 years, and recorded clinical data and morbidity. We compared patients who had reconstruction of such defects with fibular free flaps and miniplates (n=26) with those in whom biodegradable plates had been used (n=21). There was no significant difference between miniplates and biodegradable plates with regard to overall complications (p=0.45) and failure of flaps (p=0.59). After confounding factors had been adjusted for with Cox's proportional hazards regression, there was no significant difference in the proportion of patients who developed a complication between the two groups (p=0.4). The type of plate does not seem to affect overall morbidity in reconstruction of the mandible with a fibular free flap.

Safe anastomosis in laparoscopic and robotic low anterior resection for rectal cancer: a narrative review and outcomes study from an expert tertiary center

Anastomotic leak and stricture formation are recognised complications of colorectal anastomoses. Surgical technique has been implicated in its aetiology. The use of innovative anastomotic techniques and technical standardisation may facilitate risk modification. Early detection of complications using novel diagnostic tests can lead to reduction in delay of diagnosis as long as a standard system is used. We review our practice for creation a safe anastomosis for minimal invasive rectal cancer resection. Several technical points discussed and evaluated based on the evidence. We propose several recommendations aiming to standardize the technique and to minimize anastomotic complications.

Genetic Polymorphisms of the Bovine NOV Gene Are Significantly Associated with Carcass Traits in Korean Cattle

The objective of this study was to investigate single nucleotide polymorphisms (SNPs) in the bovine nephroblastoma overexpressed (NOV) gene and to evaluate whether these polymorphisms affect carcass traits in the Korean cattle population. We resequenced to detect SNPs from 24 unrelated individuals and identified 19 SNPs within the full 8.4-kb gene, including the 1.5-kb promoter region. Of these 19 SNPs, four were selected for genotyping based on linkage disequilibrium (LD). We genotyped 429 steers to assess the associations of these four SNPs with carcass traits. Statistical analysis revealed that g.7801T>C and g.8379A>C polymorphisms in the NOV gene were associated with carcass weight (p = 0.012 and 0.008, respectively), and the g.2005A>G polymorphism was associated with the back fat thickness (BF) trait (p = 0.0001). One haplotype of the four SNPs (GGTA) was significantly associated with BF (p = 0.0005). Our findings suggest that polymorphisms in the NOV gene may be among the important genetic factors affecting carcass yield in beef cattle.

Effects of Dietary Fat Types on Growth Performance, Pork Quality, and Gene Expression in Growing-finishing Pigs

This study was performed to determine the effects of dietary fat sources, i.e., beef tallow, soybean oil, olive oil and coconut oil (each 3% in feed), on the growth performance, meat quality and gene expression in growing-finishing pigs. A total of 72 crossbred pigs (Landrace×Large White×Duroc) were used at 71±1 kg body weight (about 130 d of age) in 24 pens (320×150 cm) in a confined pig house (three pigs per pen) with six replicate pens per treatment. The growing diet was given for periods of 14±3 d and the finishing diet was given for periods of 28±3 d. The fat type had no significant effect either on growth performance or on chemical composition or on meat quality in growing-finishing pigs. Dietary fat type affected fatty acid composition, with higher levels of unsaturated fatty acids (UFAs) and monounsaturated fatty acids (MUFAs) in the olive oil group. Microarray analysis in the Longissimus dorsi identified 6 genes, related to insulin signaling pathway, that were differentially expressed among the different feed groups. Real time-PCR was conducted on the six genes in the longissimus dorsi muscle (LM). In particular, the genes encoding the protein kinase, cAMP-dependent, regulatory, type II, alpha (PRKAR2A) and the catalytic subunit of protein phosphatase 1, beta isoform (PPP1CB) showed the highest expression level in the olive oil group (respectively, p<0.05, p<0.001). The results of this study indicate that the type of dietary fat affects fatty acid composition and insulin signaling-related gene expression in the LM of pigs.

Overview of anal fistula and systematic review of ligation of the intersphincteric fistula tract (LIFT)

Anal fistula management has long been a challenge for surgeons. Presently, no technique exists that is ideal for treating all types of anal fistula, whether simple or complex. A higher incidence of poor sphincter function and recurrence after surgery has encouraged the development of a new sphincter-sparing procedure, ligation of the intersphincteric fistula tract (LIFT), first described by Van der Hagen et al. in 2006. We assessed the safety, feasibility, success rate, and continence of LIFT as a sphincter-saving procedure. A literature search of articles in electronic databases published from January 2006 to August 2012 was performed. Analysis followed Preferred Reporting Items for Systematic Reviews recommendations. All LIFT-related articles published in the English language were included. We excluded case reports, abstracts, letters, non-English language articles, and comments. The procedure was described in detail as reported by Rojanasakul. Thirteen original studies, including 435 patients, were reviewed. The most common fistula procedure type was transsphincteric (92.64 %). The overall median operative time was 39 (±20.16) min. Eight authors performed LIFT as a same-day surgery, whereas the others admitted patients to the hospital, with an overall median stay of 1.25 days (range 1-5 days). Postoperative complications occurred in 1.88 % of patients. All patients remained continent postoperatively. The overall mean length of follow-up was 33.92 (±17.0) weeks. The overall mean healing rate was 81.37 (±16.35) % with an overall mean healing period of 8.15 (±5.96) weeks. Fistula recurrence occurred in 7.58 % of patients. LIFT represents a new, easy-to-learn, and inexpensive sphincter-sparing procedure that provides reasonable results. LIFT is safe and feasible, with favorable short- and long-term outcomes. However, additional prospective randomized studies are required to confirm these findings.

Adenosine triphosphate-based chemotherapy response assay-guided chemotherapy in unresectable colorectal liver metastasis

BACKGROUND

This study aims to evaluate the effectiveness of adenosine triphosphate-based chemotherapy response assay (ATP-CRA)-guided neoadjuvant chemotherapy for increasing resectability in patients with unresectable colorectal liver metastasis.

PATIENTS AND METHODS

Patients were randomised into two groups: Group A was treated by conventional chemotherapy regimen and Group B was treated by chemotherapy regimen according to the ATP-CRA. Three chemotherapeutic agents (5-fluorouracil, oxaliplatin and irinotecan) were tested by ATP-CRA and more sensitive agents were selected. Either FOLFOX or FOLFIRI was administered. Between Group A and B, treatment response and resectability were compared.

RESULTS

Between November 2008 and October 2010, a total 63 patients were randomised to Group A (N=32) or Group B (N=31). FOLFOX was more preferred in Group A than in Group B (26 out of 32 (81.3%) vs 20 out of 31 (64.5%)). Group B showed better treatment response than Group A (48.4% vs 21.9%, P=0.027). The resectability of hepatic lesion was higher in Group B (35.5% vs 12.5%, P=0.032). Mean duration from chemotherapy onset to the time of liver resection was 11 cycles (range 4-12) in Group A and 8 cycles (range 8-16) in Group B.

CONCLUSION

This study showed that tailored-chemotherapy based on ATP-CRA could improve the treatment response and resectability in initially unresectable colorectal liver metastasis.

Transanal specimen extraction in robotic rectal cancer surgery

BACKGROUND

The aim of this study was to identify the benefits of robotic transanal specimen extraction (RTSE) compared with minilaparotomy specimen extraction (MSE).

METHODS

Patients who underwent totally robotic surgery with curative intent for treatment of adenocarcinoma of the rectum below 12 cm from the anal verge were selected from the authors' database. Patients were divided into RTSE and MSE groups according to the method of specimen delivery. Clinicopathological features and perioperative surgical outcomes were compared between the two groups.

RESULTS

There were 53 patients in the RTSE group and 66 in the MSE group. No differences were observed in overall complications. Postoperative recovery was faster in the RTSE group in terms of resumption of a soft diet (mean(s.d.) 3·5(1·5) versus 4·6(1·7) days; P < 0·001) and length of hospital stay (9·0(4·8) versus 11·3(5·3) days; P = 0·016). Pain scores on a visual analogue scale were significantly lower in the RTSE group than in the MSE group from day 2 to day 5 after surgery (P = 0·021 to P < 0·001).

CONCLUSION

RTSE in robotic rectal cancer surgery was associated with less pain and a faster recovery than MSE.

CYP2A6 and ERCC1 polymorphisms correlate with efficacy of S-1 plus cisplatin in metastatic gastric cancer patients

Background:

We evaluated the association between polymorphisms of cytochrome P450 2A6 (CYP2A6)/excision repair cross-complementation group 1 (ERCC1)/X-ray repair cross-complementing group 1(XRCC1) and treatment outcomes of metastatic gastric cancer (MGC) patients treated with S-1/cisplatin.

Methods:

Among MGC patients (n=108), who received S-1 (40 mg m⁻² b.i.d., days 1–14) and cisplatin (60 mg m⁻², day 1) every 3 weeks, we analysed the wild-type allele (W) and variants (V) of CYP2A6 (*4, *7, *9, *10), and the polymorphisms of ERCC1 (rs11615, rs3212986) and XRCC1 (rs25487).

Results:

Patients having fewer CYP2A6 variants had better response rates (W/W vs W/V other than *1/*4 vs V/V or *1/*4=66.7 vs 58.3 vs 32.3% P=0.008), time to progression (TTP) (7.2 vs 6.1 vs 3.5 months, P=0.021), and overall survival (23.2 vs 15.4 vs 12.0 months, P=0.004). ERCC1 19442C>A (rs3212986) was also associated with response rate (C/C, 46.7% vs C/A, 55.3% vs A/A, 87.5%) (P=0.048) and TTP (4.4 vs 7.6 vs 7.9 months) (P=0.012). Patients carrying both risk genotypes of CYP2A6 (V/V or 1/*4) and ERCC1 19442C>A (C/C) vs those carrying none showed an adjusted odds ratio of 0.113 (P=0.004) for response, and adjusted hazard ratios of 3.748 (P=0.0001) for TTP and 2.961 (P=0.006) for death.

Conclusion:

Polymorphisms of CYP2A6 and ERCC1 19442C>A correlated with the efficacy of S-1/cisplatin.

Three phenotypes of obstructive lung disease in the elderly

SETTING

Eleven referring hospitals in South Korea.

OBJECTIVE

To classify the phenotypes in elderly subjects with obstructive lung disease (OLD).

METHODS

We analysed 191 subjects aged ≥ 60 years with chronic respiratory symptoms and either obstructive spirometry or bronchial hyperresponsiveness. Factor analysis was performed using commonly measured variables and revealed four significant variables: 1) the ratio of inspiratory capacity to total lung capacity, 2) the total score on the St George's Respiratory Questionnaire, 3) the volume fraction of the lung less than 950 Hounsfield Unit at full inspiration on volumetric computed tomography and 4) post-bronchodilator forced expiratory volume in 1 second (FEV(1)) changes. We performed a cluster analysis on these four variables.

RESULTS

The mean age was 68.5 (± 5.2 SD) years and the mean post-bronchodilator FEV(1) was 52.4% (± 16.5) predicted. Three clusters with the following phenotypes were identified: Cluster 1 included subjects with moderate to severe airflow obstruction and bronchodilator reversibility; Cluster 2 subjects had moderate airflow obstruction without bronchodilator reversibility, and Cluster 3 subjects had severe airflow obstruction without bronchodilator reversibility.

CONCLUSIONS

We identified three phenotypes in elderly subjects with OLD. Follow-up studies are needed to explore the clinical significance of each phenotype.

Phase II study of a triplet regimen of S-1 combined with irinotecan and oxaliplatin in patients with metastatic gastric cancer: clinical and pharmacogenetic results

BACKGROUND

The aim of this study was to investigate the efficacy and safety of S-1/irinotecan/oxaliplatin (TIROX) in metastatic gastric cancer (MGC) and the association between treatment outcome and uridine diphosphate-glucuronosyltransferase (UGT) 1A polymorphisms.

PATIENTS AND METHODS

Patients with previously untreated MGC received S-1 40 mg/m(2) b.i.d. on days 1-14 and irinotecan 150 mg/m(2) plus oxaliplatin 85 mg/m(2) on day 1 every 3 weeks.

RESULTS

Forty-four patients were enrolled. In intent-to-treat analysis, the objective response rate was 75%, including the complete response (CR) rate of 14%. The median time to progression and overall survival was 10.2 and 17.6 months, respectively. Ten (26%) of the 39 patients with primary gastric tumor showed biopsy-confirmed gastric CR. Grade 3/4 neutropenia developed in 66% of patients and grade 3 febrile neutropenia in 16%. The most common grade 3 nonhematologic toxic effects were abdominal pain (18%), anorexia (16%), and diarrhea (14%). UGT1A polymorphisms were associated with significantly higher incidence of grade 4 leukopenia (UGT1A1*6), neutropenia (UGT1A1*6, UGT1A6*2, and UGT1A7*3), grade 3/4 febrile neutropenia (UGT1A1*6), and grade 3 abdominal pain (UGT1A1*6).

CONCLUSIONS

The TIROX regimen induced marked tumor reduction and promising survival with a manageable toxicity profile in MGC patients. UGT1A genotype may be predictive of TIROX toxicity.

Management of gastric lymphoma with chemotherapy alone

PURPOSE

The optimal therapy for gastric lymphoma except MALToma has not yet been established. This study was undertaken to investigate whether gastric lymphoma can be managed effectively and safely with chemotherapy alone.

PATIENTS AND METHODS

A total of 58 patients (median age 56 years) with newly diagnosed gastric lymphoma between 1989--2001 at Seoul National University Hospital and who were initially managed with chemotherapy alone were evaluated. MALToma was excluded from the pathologic review.

RESULTS

All patients received initially anthracycline-containing chemotherapy. ECOG performance scale 0--1 was 88% and B symptoms were present in 41.4%. Diffuse large B cell type was the most common (74.1%). Stage IE, II1E accounted for 51.7% and II2E, IIIE, IV for 48.3%. The international prognostic index (IPI) of risk was low in 39.7%, low-intermediate in 22.4%, high-intermediate in 15.5% and high in 22.4%. The complete response rate after first-line chemotherapy was 71.4% and the partial response rate was 12.2%. (overall response rate: 83.6%). Among patients who did not reach the complete response, a further complete response was achieved by second-line chemotherapy including etoposide-based regimen. Ultimately, the maximum complete response rate by chemotherapy was 83.7% (92% in stage IE, II1E, 75% in stage II2E, IIIE, IV). Median overall survival was 47.4 months (84.7 months in stage IE, II1E, 32.5 months in stage II2E, IIIE, IV) and the 5-year survival rate was 46%. Bleeding as a complication occurred in 3 of 58 patients (5.6%) and these cases were controlled by embolization or conservative management. No perforation episode occurred and surgical intervention due to complication was not necessary. Organ preservation was possible in 57 of 58 patients (98%). The one gastrectomy was performed due to a partial clinical response to chemotherapy but the specimen showed pathologic CR. Multivariate analysis revealed that only IPI had a significant influence on survival.

CONCLUSIONS

Gastric lymphoma except MALToma can be managed effectively and safely with chemotherapy alone.

ACE I/D polymorphism in Korean patients with ischemic stroke and silent brain infarction

OBJECTIVES

Angiotensin-converting enzyme (ACE) polymorphism may play a role in stroke and silent brain infarction (SBI) susceptibility, but the results among the populations studied to date have not been consistent. Thus, we investigated the association between ACE genotypes and ischemic stroke and SBI in Korean patients.

SUBJECTS AND METHODS

DNA samples from 237 stroke patients, 264 SBI patients and 234 age-matched controls were amplified using polymerase chain reaction to detect the ACE ins/del (I/D) polymorphism. Genotype was determined by the presence of a 490-bp band (I allele) or a 190-bp band (D allele) in agarose gel electrophoresis.

RESULTS

Odds ratios of the I/D and D/D genotypes and the overall (I/D + D/D) for the I/I genotype were significantly different between stroke patients and normal controls. However, there was no significant difference between patients with SBI and controls.

CONCLUSIONS

This study is the first report of a significant association between ACE polymorphism and ischemic stroke in the Asian population. Although no consistent associations have been found between ACE polymorphism and stroke in the populations studied to date, the ACE polymorphism may be a genetic determinant of ischemic stroke, at least in Korean patients.

Belotecan, new camptothecin analogue, is active in patients with small-cell lung cancer: results of a multicenter early phase II study

BACKGROUND

Belotecan (Camtobell, Chong Keun Dang Corp, Seoul, Korea; CKD602) is a new camptothecin analogue. This study aimed to investigate the safety and efficacy of single-agent belotecan for small-cell lung cancer (SCLC).

PATIENTS AND METHODS

Twenty-seven patients with chemotherapy-naive or chemosensitive SCLC were treated with belotecan 0.5 mg/m(2)/day on days 1-5 of a 3-week cycle. All 27 patients were assessable for toxicity, and 21 patients assessable for response.

RESULTS

Nine patients (42.9%) showed objective tumor responses including one complete response; seven (63.6%) in 11 chemotherapy-naive patients; and two (20.0%) in 10 chemosensitive patients. With a median follow-up of 5 years, median progression-free and survival time for chemotherapy-naive patients were 4.8 months and 11.9 months, respectively, while the corresponding values for chemosensitive patients were 3.3 months and 10.5 months, respectively. The most common toxicity was neutropenia.

CONCLUSION

Belotecan was active in SCLC patients as a single agent, warranting further investigations of belotecan in combination with platinum or other active agents.

Targeted RNA interference of phosphatidylinositol 3-kinase p110-beta induces apoptosis and proliferation arrest in endometrial carcinoma cells

Phosphatidylinositol 3-kinase (PI3K) signalling plays a pivotal role in intracellular signal transduction pathways involved in cell growth, cellular transformation, and tumourigenesis. PI3K is overexpressed in many human cancers, including endometrial carcinomas, one of the most common female genital tract malignancies. Here, we used small interfering RNA (siRNA) targeted to PI3K p110-beta to determine whether inhibition of the beta isoform could be a potential therapeutic target for endometrial carcinoma. In this study, treatment of HEC-1B endometrial cancer cells with PI3K p110-beta-specific siRNA resulted in increased apoptosis and decreased tumour cell proliferation. Depletion of PI3K p110-beta decreased the protein levels of AKT1, AKT2, pAKT, and mTOR-downstream targets of PI3K. Knock-down of PI3K p110-beta by siRNA also induced decreased expression of cyclin E and Bcl-2, suggesting that PI3K p110-beta stimulates tumour growth, at least in part by regulating cyclin E and Bcl-2. Thus, our results indicate that siRNA-mediated gene silencing of PI3K p110-beta may be a useful therapeutic strategy for endometrial cancers overexpressing PI3K p110-beta.

A prospective comparison study for predicting circumferential resection margin between preoperative MRI and whole mount sections in mid-rectal cancer: significance of different scan planes

AIM

The aim of this study is to evaluate the accuracy of preoperative magnetic resonance imaging (MRI) in the prediction of circumferential resection margin (CRM) and to determine whether each different MRI scan plane provides an accurate CRM assessment.

METHOD

Fifty-seven consecutive patients with mid-rectal cancer were enrolled prospectively. The CRM measurement from each MRI plane according to tumor location was compared with CRM measurement on whole-mount sections with the definition of threatened CRM as 2 mm in distance. The difference in performance among the sagittal, axial and oblique MR images was analyzed by using receiver operating characteristic (ROC) curves (A(z)).

RESULTS

For anterior tumors (n = 17), the A(z) of the sagittal, axial and oblique MR planes were 0.66, 0.83 and 0.79, respectively. For lateral tumors (n = 17), the A(z) of the sagittal, axial and oblique MR planes were 0.53, 0.66 and 0.78, respectively. For posterior tumors (n = 23), the A(z) of the sagittal, axial and oblique MR planes were 0.76, 0.82 and 0.97, respectively.

CONCLUSIONS

MRI provides an accurate prediction of preoperative CRM. There exist differences in diagnostic accuracy according to each different scan plane of MRI and tumor location within the rectum.

Antibiotic use during the last days of life in cancer patients

The purpose of this study is to document infection and to better understand current practice relating to antibiotic use and its effect in terminal cancer patients. We retrospectively reviewed patients with terminal stage cancer who were admitted to Seoul National University Boramae Hospital for symptom control only, and who finally died between March 2003 and April 2004. A total of 141 patients were enrolled. Mean duration from admission to death was 31.2 days. A total of 104 patients (75.2%) experienced a febrile episode, and physicians considered 113 patients (80.1%) developed a clinical infection. Total 119 patients (84.4%) received antibiotics. For 90 patients (63.8%), antibiotics were used until the day of death. After using antibiotics, 48% of fevers were controlled, and 31% of organism-proven cases were resolved. Symptomatic improvement of infection was achieved in 18 patients (15.1%), but 66 patients (55.4%) showed no improvement. Improved leucocytosis was achieved by 17% and C Reactive Protein elevation by 29%. In conclusion, our study reveals a high rate of infection and a high rate of antibiotic prescription during the last month of life in cancer patients. But symptomatic improvement was not achieved in more than half of the patients. Further study should be undertaken to clarify the benefit of antibiotics in terminal stage cancer patients.

Clipping vs coiling of posterior communicating artery aneurysms with third nerve palsy

The authors investigated the evolution of third nerve palsy in patients with posterior communicating artery aneurysms who underwent coiling vs clipping. There was no statistical difference of complete third nerve palsy recovery in both treatments. Both techniques were of clinical benefit. Older age, diabetes, delayed interventions, and complete third nerve palsy at presentation indicated a poor prognosis for recovery.

Hyperhomocysteinemia as an independent risk factor for silent brain infarction

OBJECTIVE

To evaluate whether hyperhomocysteinemia is an independent risk factor for silent brain infarction (SBI), and to determine the relationship between homocysteine and folate in each type of methylenetetrahydrofolate reductase (MTHFR) polymorphism, in order to identify a way of reducing the risk for SBI.

METHODS

The authors enrolled 161 patients with SBI and 126 healthy people, checked their fasting homocysteine and folate levels, and analyzed for the MTHFR C677T polymorphism.

RESULTS

The mean plasma homocysteine level in patients with SBI (12.17 +/- 5.35 micro mol/L) was significantly higher than in normal healthy people (9.37 +/- 4.11 micro mol/L; p < 0.05). By subgroup analysis, based on the classification of plasma homocysteine levels as high (>or=11.77 micro mol/L), moderate (8.71 to 11.76 micro mol/L), and low (<or=8.70 micro mol/L), the adjusted OR (AOR) of the high group for SBI was significantly greater than that of the low group (AOR, 4.78; 95% CI, 2.45 to 9.33). The homocysteine level showed a significant inverse correlation with folate level only in patients with SBI with the MTHFR 677TT genotype (p < 0.05).

CONCLUSIONS

This study demonstrates that hyperhomocysteinemia is an independent risk factor for SBI, and provides the possibility of reducing the risk for SBI in the MTHFR 677TT genotype by folate supplementation.

Adrenal cortical carcinoma initially presented with overwhelming disseminated intravascular coagulation

We report a 54-year-old man who had adrenal cortical carcinoma initially manifested as features of overwhelming disseminated intravascular coagulation (DIC). In the initial diagnostic work-up, an adrenal mass was detected with venous thrombi in the abdominal imaging study, but the radiologic diagnosis was a hematoma arising from the adrenal gland and a biopsy was not possible due to a bleeding tendency. A lot of platelets and plasma products were transfused, but the bleeding tendency and other DIC features persisted. Finally, he expired because of newly developed massive pulmonary thromboembolism. To our knowledge, this is the first reported case of adrenal cortical carcinoma complicated with bleeding tendency caused by DIC as an initial manifestation. This suggests that adrenal cortical carcinoma should be considered in a patient with an adrenal mass and DIC features.

Phase II study of oxaliplatin, 5-fluorouracil and leucovorin in previously platinum-treated patients with advanced gastric cancer

BACKGROUND

Oxaliplatin shows preclinical activity in many cancer cell lines that are resistant to cisplatin, and also has synergism with 5-fluorouracil (5-FU). We undertook this study to evaluate the efficacy and toxicities of a combined oxaliplatin, 5-FU and leucovorin (LV) continuous infusion regimen in patients with advanced gastric cancer who progressed during or after treatment with 5-FU and platinum compounds.

PATIENTS AND METHODS

Twenty-six patients with advanced gastric cancer, whose disease progressed while receiving, or after discontinuing, chemotherapy with a 5-FU and platinum regimen, were enrolled in this study. Treatment comprised oxaliplatin (85 mg/m2 on day 1) as a 2-h infusion followed by bolus 5-FU (400 mg/m2 on day 1), and 48-h infusion of 5-FU 2.4-3.0 g/m2 concurrently with LV 150 mg/m2. Cycles were repeated at 2-week intervals.

RESULTS

Of the 23 evaluable patients, there were six partial responses (response rate 26%). All responding patients were among those who entered into this trial immediately after failure of previous chemotherapy with 5-FU and cisplatin. The median time to progression was 4.3 months and the median overall survival was 7.3 months. The most common hematologic toxicity was grade 1-2 anemia in 39 cycles (39%). No grade 4 leukopenia or thrombocytopenia were observed. The most common non-hematologic toxicity was nausea/vomiting (33%). Peripheral neuropathy of grade 1 or 2 was noted (27%), but there was no grade 3 or 4 neurotoxicity.

CONCLUSIONS

This phase II study of oxaliplatin, 5-FU and LV continuous infusion showed activity in previously platinum-treated patients with advanced gastric cancer, with acceptable toxicities.

Acquired activated protein C resistance, high tissue factor expression, and hyper-homocysteinemia in systemic lupus erythematosus

Activated protein C resistance (APCR), high tissue factor (TF) expression, and hyper-homocysteinemia are associated with thromboembolic diseases. Thromboembolism is a frequent complication of systemic lupus erythematosus (SLE). In this study, we evaluated the prevalence of APCR, high TF, and homocysteine with correlation of the thrombotic tendency in SLE. Ninety-four SLE patients and 28 normal controls were included. APC ratio and TF antigen were measured using commercial kits. Plasma homocysteine level was measured using HPLC. The prevalence of APCR, high TF antigen level, and hyper-homocysteinemia in our SLE patients were 21.3%, 66.0%, and 23.4%, respectively. The median plasma level of TF antigen in SLE patients was 145.23 pg/mL (range, 31.00-778.50 pg/mL), which was significantly higher than the control value of 39.83 pg/mL (range, 1.55-168.50 pg/mL). The median APC ratio in SLE patients was 2.76 (range, 1.48-13.47), which was significantly lower than the control value of 3.59 (range, 0.26-5.66). The plasma level of homocysteine was not significantly different from that of control. A significant association was observed between the presence of APCR (OR = 8.59, P < 0.0001) but not with the presence of high plasma TF antigen level (OR = 1.24, P = 0.67) and thrombotic complications in SLE patients. In conclusion, APCR and high plasma TF levels are common in SLE, but a significant association was observed only between the presence of APCR and thrombosis in SLE patients.

Homozygous C677T mutation in the MTHFR gene as an independent risk factor for multiple small-artery occlusions

INTRODUCTION

Hyperhomocysteinemia is an independent risk factor for cerebrovascular disease and the homozygous C677T mutation in the methylenetetrahydrofolate reductase (MTHFR) gene can induce hyperhomocysteinemia. However, the association between this 677TT genotype and ischemic stroke still remains controversial. Therefore, we carried out this study to determine whether the MTHFR TT genotype is associated with certain subtypes of ischemic stroke.

MATERIALS AND METHODS

We enrolled 195 ischemic stroke patients and 198 healthy individuals and checked their fasting plasma homocysteine levels and analyzed the C677T polymorphism in the MTHFR gene.

RESULTS

Our findings concur with previous reports that stroke occurrence is associated with hyperhomocysteinemia, but not with the 677TT genotype. However, when we re-analyzed the data based on a subtype classification, the adjusted odds ratio (AOR) and 95% confidence intervals (CI) of the 677TT genotype were found to be significantly higher in patients with small-artery occlusion than that in controls (AOR, 2.92; 95% CI, 1.01-8.48). Moreover, the AOR of the 677TT genotype was found to be much bigger in patients with multiple small-artery occlusions (AOR, 6.90; 95% CI, 1.70-27.99), but not in those with single small-artery occlusion (AOR, 1.19; 95% CI, 0.27-5.35).

CONCLUSIONS

The homozygous C677T mutation in the MTHFR gene is associated with multiple small-artery occlusions, but not with single small-artery occlusion. Our findings suggest a genetic basis for certain subtypes of ischemic stroke.

A phase III randomized trial of 5-fluorouracil, doxorubicin, and mitomycin C versus 5-fluorouracil and mitomycin C versus 5-fluorouracil alone in curatively resected gastric cancer

BACKGROUND

A phase III single-center randomized trial was performed in order to determine whether the addition of mitomycin C (MMC) and/or doxorubicin to 5-fluorouracil (5-FU) as adjuvant chemotherapy could influence survival in patients with curatively resected gastric cancer.

PATIENTS AND METHODS

A total of 416 patients who had undergone curative resection for stage IB-IIIB gastric adenocarcinoma were stratified according to the stage and type of surgery, and then randomized to receive one of the three chemotherapy regimens, 5-FU alone (F) or 5-FU and MMC (FM) or 5-FU, doxorubicin and MMC (FAM) within 5 weeks after surgery.

RESULTS

Of 416 patients registered, 395 (133 in F, 131 in FM and 131 in FAM) were assessable. Median follow-up duration was 91 months. Five-year overall survival rates were 67.2% for F, 67.0% for FM and 66.7% for FAM (P = 0.97). Five-year disease-free survival rates were 62.1% for F, 63.3% for FM and 62.5% for FAM (P = 0.83). Hematological toxicities were more frequent in the FM and FAM groups, whereas stomatitis was more common in the F group.

CONCLUSIONS

Compared with adjuvant 5-FU alone, the addition of MMC and/or doxorubicin to 5-FU did not influence survival in patients with resected gastric cancer.

Ramosetron for the prevention of cisplatin-induced acute emesis: a prospective randomized comparison with granisetron

Control of nausea and vomiting is very important in determining patient compliance with cisplatin chemotherapy. A multicentre, randomized, single-blind study was conducted to compare the tolerability and efficacy of ramosetron with those of granisetron over 24 h following cisplatin administration to cancer patients. In eight study centres, a total of 194 adult patients were randomly assigned to receive either intravenous ramosetron 0.3 mg or intravenous granisetron 3.0 mg. The anti-emetic effect of ramosetron determined from the no-vomiting rate lasted longer, but there was no significant difference in the number of acute vomiting episodes or the severity of nausea between the two groups. In the tolerability evaluation, there were no statistically significant differences between the two groups, except for a higher incidence of dull headache in the granisetron group. Ramosetron and granisetron appear to have equivalent efficacy and tolerability profiles, but the effects of ramosetron on the prevention of acute vomiting in patients undergoing cisplatin chemotherapy were longer lasting.

Analysis of errors in medical rapid prototyping models

Rapid prototyping (RP) is a relatively new technology that produces physical models by selectively solidifying UV-sensitive liquid resin using a laser beam. The technology has gained a great amount of attention, particularly in oral and maxillofacial surgery. An important issue in RP applications in this field is how to obtain RP models of the required accuracy. We investigated errors generated during the production of medical RP models, and identified the factors that caused dimensional errors in each production phase. The errors were mainly due to the volume-averaging effect, threshold value, and difficulty in the exact replication of landmark locations. We made 16 linear measurements on a dry skull, a replicated three-dimensional (3-D) visual (STL) model, and an RP model. The results showed that the absolute mean deviation between the original dry skull and the RP model over the 16 linear measurements was 0.62 +/- 0.35 mm (0.56 +/- 0.39%), which is smaller than values reported in previous studies. A major emphasis is placed on the dumb-bell effect. Classifying measurements as internal and external measurements, we observed that the effect of an inadequate threshold value differs with the type of measurement.

Phase II Trial of Vinorelbine and Cisplatin Chemotherapy in Advanced Non-Small Cell Lung Cancer

PURPOSE

Platinum-based chemotherapy has conferred a modest but significant survival benefit and the introduction of newer drugs has led to achieve higher response rate in patients with advanced non-small cell lung cancer (NSCLC). We performed a phase II trial in order to evaluate the efficacy and toxicity of combination chemotherapy with vinorelbine (Navelbine) and cisplatin in advanced NSCLC.

MATERIALS AND METHODS

Patients with previously untreated, unresectable stage IIIB or IV NSCLC with measurable lesion (s) were eligible for entry into the study. NP chemotherapy consisted of intravenous vinorelbine 25 mg/m2, on day 1 and 8, and intravenous cisplatin 80 mg/m2 on day 1; this cycle was repeated every three weeks.

RESULTS

A total of 33 patients were enrolled in the study between July 1999 and Feb 2000. Of the 30 patients deemed eligible for analysis, thirteen patients achieved a partial response and thirteen showed a stable disease. The overall response rate was 43.3%. The median duration of response was 5.7 months (95% CI: 2.8~8.5 months). The median time to progression was 7.6 months (95% CI: 5.5~9.7 months) and the overall median survival time was 15.1 months (95% CI: 9.8~20.4 months) in the intent-to-treat analysis. Chemotherapy-related grade 3 or 4 toxicities were anemia in 1.5%, leukopenia in 4.5%, nausea/vomiting in 2.3%, alopecia in 13.3%, and neurotoxicity in 3.3%.

CONCLUSION

The combination of vinorelbine and cisplatin chemotherapy seems to be active and fairly tolerable in patients with advanced NSCLC.

Cyclin E overexpression as an independent risk factor of visceral relapse in breast cancer

AIM

Prognostic value of the cyclin E overexpression in breast cancer has not been clearly established, especially in relation to the pattern of recurrence. We investigated the implication of cyclin E overexpression for the pattern of recurrence in Korean breast cancer patients.

METHODS

Using immunohistochemical methods, we retrospectively examined the cyclin E expression level in breast cancer specimens from 128 women who underwent curative breast surgery, and correlated the levels of expression with the pattern of relapse in patients.

RESULTS

Cox model-based multivariate analysis indicated that distant relapse could be predicted by the number of positive axillary lymph nodes, high cyclin E expression, and the younger age (<35 years) of the patient. We tested further the association of cyclin E overexpression with the specific types of recurrence; multivariate analyses indicated that adjusted relative risks of bone and visceral relapse as the first events among high cyclin E group were 2.46 (95% confidence interval (CI), 0.86-7.02) (P=0.092), and 3.98 (95% CI, 1.23-12.94) (P=0.022), respectively. On the other hand, cyclin E overexpression was not associated with the risk of locoregional relapse.

CONCLUSION

Our data suggest that cyclin E overexpression in primary breast carcinoma tissue could independently predict the risk of distant relapse, especially of visceral relapse, as the first failure after curative breast surgery.

Ultralow anterior resection and coloanal anastomosis for distal rectal cancer: functional and oncological results

We evaluated the functional and oncological outcome of ultralow anterior resection and coloanal anastomosis (CAA), which is a popular technique for preserving anal sphincter in patients with distal rectal cancer. Forty-eight patients were followed up for 6-100 months regarding fecal or gas incontinence, frequency of bowel movement, and local or systemic recurrence. The main operative techniques were total mesorectal excision with autonomic nerve preservation; the type of anastomosis was straight CAA, performed by the perianal hand sewn method in 38 cases and by the double-stapled method in 10. Postoperative complications included transient urinary retention (n=7), anastomotic stenosis (n=3), anastomotic leakage (n=3), rectovaginal fistula (n=2), and cancer positive margin (n=1; patient refused reoperation). Overall there were recurrences in seven patients (14.5%): one local and one systemic recurrence in stage B2; and one local, two systemic, and two combined local and systemic in C2. The mean frequency of bowel movements was 6.1 per day after 3 months, 4.4 after 1 year, and 3.1 after 2 years. The Kirwan grade for fecal incontinence was 2.7 after 3 months, 1.8 after 1 year, and 1.5 after 2 years. With careful selection of patients and good operative technique, CAA can be performed safely in distal rectal cancer. Normal continence and acceptable frequency of bowel movements can be obtained within 1 year after operation without compromising the rate of local recurrence.

Increased expression and localization of a serine protease inhibitor, protease nexin-1 (PN-1), in the ovary and uterus during implantation in rat

Protease nexin-1 (PN-1) is a serine protease inhibitor (serpin) that inactivates several proteases, including thrombin, urokinase, plasminogen activators (PA), and plasmin. It also plays a role in regulating proteolytic activity generated by PA system. PN-1 is known to be involved in tissue remodeling, cellular invasiveness, matrix degradation, and tumor growth. However, the role of PN-1 in female reproductive tracts, such as the uterus, ovary, and oviduct, during pregnancy is not known. The present study was designed to investigate the changes of PN-1 mRNA level and localization in the tracts during implantation and early pregnancy by using reverse transcription (RT)-polymerase chain reaction (PCR) and in situ hybridization. We found that PN-1 mRNA levels were coordinately regulated during early pregnancy in a stage- and tissue-specific manner, such that an increased expression of PN-1 gene appeared at the time of the implantation period in the uterus and ovary. Both the uterus and ovary synthesized PN-1 mRNA and their maximal PN-1 expression occurred on Day 6.5 postcoitum (p.c.). On 13.5 days of pregnancy, PN-1 level was low in the uterus and ovary. On the other hand, PN-1 mRNA in the oviduct did not show after 6.5 days of pregnancy. It appears that PN-1 mRNA in the uterus and ovary was highly regulated during early pregnancy, which might have an important role in implantation of rat blastocysts. PN-1 was localized in endometrial stromal cells of the uterus and in granulosa cells of the unstimulated primary follicles in the ovary during periimplantation period. Also, PN-1 mRNA expression was higher at implantation period than that at nonimplantation period of pregnancy. In conclusion, PN-1 is expressed in female reproductive tracts and highly regulated during implantation and early pregnancy.

Gene amplification and expression of the DNA repair enzyme, N-methylpurine-DNA glycosylase (MPG) in HPV-infected cervical neoplasias

BACKGROUND

Lethal and mutagenic damages of DNA is caused by a variety of agents including viruses. It is known that HPV is one of the major causes of cervical carcinogenesis and that cells eliminate DNA lesions with DNA repair enzymes. However, the role of N-methylpurine-DNA glycosylase (MPG) is not known in the development of cervical cancer.

MATERIALS AND METHODS

Multiplex polymerase chain reaction (PCR) was used for the detection and typing of HPV in the biopsy. Gene amplification of MPG was measured by a PCR-based assay. The mRNA levels of MPG were determined by reverse transcription-PCR using hypoxanthine-guanine phosphoribosyl transferase as the reference gene. An immunohistochemical technique was used to examine the distribution of MPG in the tissues.

RESULTS

Of 68 Korean cervical neoplasia patients, 86.8% showed HPV infection. High-risk HPV 16/18 were the most prevalent but positive only in 47.3% of the invasive cancer patients. Gene amplification of MPG was significantly increased in high-risk HPV-infected tissues as compared to low-risk HPV-infected and normal tissues (p < 0.05). The mRNA levels of MPG were higher in HPV-infected invasive carcinoma than normal cervical tissues. Immunohistochemical staining revealed that the intracellular expression and distribution (localization) of MPG altered in the cervical neoplasia. Interestingly, MPG expression in CIN III and invasive carcinoma (IC) was much higher than normal and CIN I. Granular positivity of MPG was notable in the perinuclear regions of the cytoplasm in HPV-infected invasive cancer.

CONCLUSION

This is the first report on MPG expression in cervical neoplasia. Our results indicate that the gene amplification and expression of MPG were increased in high-risk HPV-infected cervical neoplasias and the intracellular distribution of MPG protein was altered, suggesting a role of MPG in carcinogenesis.

Prognostic factors of Krukenberg's tumor

OBJECTIVE

The aim of this study was to determine prognostic factors of metachronous Krukenberg's tumors of gastric origin, thereby helping to establish a therapeutic plan for this rare entity.

METHODS

Thirty-four female patients who underwent curative resection of gastric carcinoma from 1987 through 1996 and subsequently developed Krukenberg's tumors were identified. The covariates used for survival analysis were patient age at the time of ovarian relapse (categorized as <50 years or >/=50 years), size of Krukenberg's tumor (categorized as </=5, 5-10, or >10 cm), initial AJCC stage of gastric carcinoma, relapse-free interval (categorized as <1, 1-2, or >/=2 years), extent of recurrent disease, and the presence of gross residual disease after treatment for Krukenberg's tumors. The influence of all covariates on the survival period was assessed using the Cox proportional hazards model.

RESULTS

At a median follow-up of 32.3 months (range, 2.2-83.1), the median survival period of 34 study patients was estimated to be 7.7 months (95% confidence interval (CI), 5.8-9.6) after the diagnosis of metachronous Krukenberg's tumor. Cox-model-based survival analysis demonstrated that the absence of residual disease after treatment and limited disease extent were favorable prognostic factors. The median survival period of patients without gross residual disease was longer (10.9 months (95% CI, 4.6-17.1)) than that of patients with gross residual disease (7.5 months (95% CI, 6.6-8.3)) [P = 0.036]. Median survival periods according to the extent of metastasis were 10.9 months (95% CI, 0-23.0) for patients with disease confined to the ovaries, 13.1 months (95% CI, 5.9-20.3) for patients with disease confined to the pelvis, 7.5 months (95% CI, 6.8-8.1) for patients with intraabdominal disease, and 3.6 months (95% CI, 3.4-3.7) for patients with disease spread outside the abdomen and pelvis [P = 0.003]. In contrast, patient age, size of ovarian tumor, initial stage of gastric adenocarcinoma, and relapse-free interval were not prognostic indicators for survival after the development of ovarian metastases.

CONCLUSION

The absence of residual disease after treatment and limited disease extent were favorable prognostic factors of metachronous Krukenberg's tumors of stomach origin. Our data suggest that resection might have a role in the management of Krukenberg's tumors of stomach origin if it could render patients free of gross residual disease.

p53, BCL-2, and Ki-67 expression according to tumor response after concurrent chemoradiotherapy for advanced rectal cancer

BACKGROUND

Concurrent chemoradiotherapy (CCRT) for locally advanced rectal cancer is an important modality for curative resection, but tumors show wide spectrum response. The purpose of this study was to investigate any correlation among related genetic mutations, proliferative index, and tumor response after CCRT.

METHODS

This study included 23 patients with rectal cancer, who were preoperatively staged as at least T3 N1 or T4 (determined by transrectal ultrasonography and MRI). Enrolled patients were given 5-FU 450 mg/m2/day and leucovorin 20 mg/m2/day intravenously for 5 days during weeks 1 and 5 of radiotherapy (45-54 Gy). Surgical resection was performed 4 weeks after completion of the scheduled treatment. Tumor response was classified as CR (complete response), PR (partial response: 50% diminution of tumor volume and downstaging), and NR (no response). Paraffin-embedded tissue obtained before chemoradiotherapy was studied by immunohistochemical staining for p53, BCL-2, and Ki-67. The extent of tumor response was correlated with proliferative activity and was measured by immunostaining Ki-67 proliferative antigen and the expression of p53 and BCL-2 oncoproteins.

RESULTS

All patients were resectable. CR was obtained in 4 patients, PR in 10 patients, and NR in 9 patients. The p53 mutation was noted in 16 patients: NR in 5 patients, PR in 9 patients, and CR in 2 patients (P = .638). BCL-2 expression was noted in 11 patients: NR in 4 patients, PR in 3 patients, and CR in 4 patients (P = .799). The Ki-67 labeling index was NR: 615.4+/-47.2; PR: 663.2+/-20.4; and CR: 765.5+/-58.3 (CR + PR vs. NR, P = .029).

CONCLUSIONS

Immunohistochemical expression of p53 and BCL-2 does not correlate with tumor response after CCRT, but Ki-67 labeling may be a useful parameter for radiosensitive tumors selected for CCRT.