Power Doppler signal at the enthesis and bone erosions are the most discriminative OMERACT ultrasound lesions for SpA: results from the DEUS (Defining Enthesitis on Ultrasound in Spondyloarthritis) multicentre study

OBJECTIVES

To assess, in spondyloarthritis (SpA), the discriminative value of the Outcome Measures in Rheumatology (OMERACT) ultrasound lesions of enthesitis and their associations with clinical features in this population.

METHODS

In this multicentre study involving 20 rheumatology centres, clinical and ultrasound examinations of the lower limb large entheses were performed in 413 patients with SpA (axial SpA and psoriatic arthritis) and 282 disease controls (osteoarthritis and fibromyalgia). 'Active enthesitis' was defined as (1) power Doppler (PD) at the enthesis grade ≥1 plus entheseal thickening and/or hypoechoic areas, or (2) PD grade >1 (independent of the presence of entheseal thickening and/or hypoechoic areas).

RESULTS

In the univariate analysis, all OMERACT lesions except enthesophytes/calcifications showed a significant association with SpA. PD (OR=8.77, 95% CI 4.40 to 19.20, p<0.001) and bone erosions (OR=4.75, 95% CI 2.43 to 10.10, p<0.001) retained this association in the multivariate analysis. Among the lower limb entheses, only the Achilles tendon was significantly associated with SpA (OR=1.93, 95% CI 1.30 to 2.88, p<0.001) in the multivariate analyses. Active enthesitis showed a significant association with SpA (OR=9.20, 95% CI 4.21 to 23.20, p<0.001), and unlike the individual OMERACT ultrasound lesions it was consistently associated with most clinical measures of SpA disease activity and severity in the regression analyses.

CONCLUSIONS

This large multicentre study assessed the value of different ultrasound findings of enthesitis in SpA, identifying the most discriminative ultrasound lesions and entheseal sites for SpA. Ultrasound could differentiate between SpA-related enthesitis and other forms of entheseal pathology (ie, mechanical enthesitis), thus improving the assessment of entheseal involvement in SpA.

Reliability assessment of ultrasound muscle echogenicity in patients with rheumatic diseases: Results of a multicenter international web-based study

Objectives

To investigate the inter/intra-reliability of ultrasound (US) muscle echogenicity in patients with rheumatic diseases.

Methods

Forty-two rheumatologists and 2 radiologists from 13 countries were asked to assess US muscle echogenicity of quadriceps muscle in 80 static images and 20 clips from 64 patients with different rheumatic diseases and 8 healthy subjects. Two visual scales were evaluated, a visual semi-quantitative scale (0-3) and a continuous quantitative measurement ("VAS echogenicity," 0-100). The same assessment was repeated to calculate intra-observer reliability. US muscle echogenicity was also calculated by an independent research assistant using a software for the analysis of scientific images (ImageJ). Inter and intra reliabilities were assessed by means of prevalence-adjusted bias-adjusted Kappa (PABAK), intraclass correlation coefficient (ICC) and correlations through Kendall's Tau and Pearson's Rho coefficients.

Results

The semi-quantitative scale showed a moderate inter-reliability [PABAK = 0.58 (0.57-0.59)] and a substantial intra-reliability [PABAK = 0.71 (0.68-0.73)]. The lowest inter and intra-reliability results were obtained for the intermediate grades (i.e., grade 1 and 2) of the semi-quantitative scale. "VAS echogenicity" showed a high reliability both in the inter-observer [ICC = 0.80 (0.75-0.85)] and intra-observer [ICC = 0.88 (0.88-0.89)] evaluations. A substantial association was found between the participants assessment of the semi-quantitative scale and "VAS echogenicity" [ICC = 0.52 (0.50-0.54)]. The correlation between these two visual scales and ImageJ analysis was high (tau = 0.76 and rho = 0.89, respectively).

Conclusion

The results of this large, multicenter study highlighted the overall good inter and intra-reliability of the US assessment of muscle echogenicity in patients with different rheumatic diseases.

Reliability assessment of the definition of ultrasound enthesitis in SpA: results of a large, multicentre, international, web-based study

OBJECTIVES

To investigate the reliability of the OMERACT US Task Force definition of US enthesitis in SpA.

METHODS

In this web exercise, based on the evaluation of 101 images and 39 clips of the main entheses of the lower limbs, the elementary components included in the OMERACT definition of US enthesitis in SpA (hypoechoic areas, entheseal thickening, power Doppler signal at the enthesis, enthesophytes/calcifications, bone erosions) were assessed by 47 rheumatologists from 37 rheumatology centres in 15 countries. Inter- and intra-observer reliability of the US components of enthesitis was calculated using Light's kappa, Cohen's kappa, Prevalence And Bias Adjusted Kappa (PABAK) and their 95% CIs.

RESULTS

Bone erosions and power Doppler signal at the enthesis showed the highest overall inter-reliability [Light's kappa: 0.77 (0.76-0.78), 0.72 (0.71-0.73), respectively; PABAK: 0.86 (0.86-0.87), 0.73 (0.73-0.74), respectively], followed by enthesophytes/calcifications [Light's kappa: 0.65 (0.64-0.65), PABAK: 0.67 (0.67-0.68)]. This was moderate for entheseal thickening [Light's kappa: 0.41 (0.41-0.42), PABAK: 0.41 (0.40-0.42)], and fair for hypoechoic areas [Light's kappa: 0.37 (0.36-0.38); PABAK: 0.37 (0.37-0.38)]. A similar trend was observed in the intra-reliability exercise, although this was characterized by an overall higher degree of reliability for all US elementary components compared with the inter-observer evaluation.

CONCLUSIONS

The results of this multicentre, international, web-based study show a good reliability of the OMERACT US definition of bone erosions, power Doppler signal at the enthesis and enthesophytes/calcifications. The low reliability of entheseal thickening and hypoechoic areas raises questions about the opportunity to revise the definition of these two major components for the US diagnosis of enthesitis.

Ultrasound measurement of muscle thickness at the anterior thigh level in rheumatology setting: a reliability study

Ultrasound (US) is a promising tool for assessing sarcopenia. We aimed to test in the rheumatology setting two US scanning protocols to measure muscle thickness (MT) at the anterior thigh level and to assess their feasibility and reliability. In the first phase of the study, three rheumatologists performed a US examination on 19 consecutive patients adopting two scanning protocols, namely the anterior superior iliac spine (ASIS) and the greater trochanter techniques. After consensus was obtained on the easiest scanning protocol to perform, two rheumatologists adopted only the ASIS technique in 40 consecutive patients. MT measurements were recorded as well as the time needed to complete each scanning protocol bilaterally. The median time needed to complete the US examination was under 5 minutes for each of the two techniques, with no significant difference between them (p = 0.64). In the first phase, we found an excellent inter-observer reliability of the proposed scanning protocols, with a higher but nonstatistically significant intraclass correlation coefficient (ICC) for the ASIS technique compared with the greater trochanter technique (ICC 0.97 vs. ICC 0.92, p = 0.05). The ASIS technique had a significantly higher intra-observer reliability (ICC 0.97 vs. ICC 0.92, p < 0.01). In the second phase, the ASIS technique confirmed on a larger sample its excellent inter-observer reliability, with an ICC of 0.96. The present study presents a novel tool for assessing sarcopenia and provides evidence in favor of feasibility and reliability of US measurement of MT at the anterior thigh level in rheumatology setting. Key Points • This study demonstrates that ultrasound (US) measurement of muscle thickness at the anterior thigh level is highly reliable, especially for the "anterior superior iliac spine (ASIS)" technique. • The short time needed to complete the US assessment highlights the feasibility of the proposed scanning protocols. • The simplicity and conciseness of the proposed techniques will allow other researchers and clinicians to use it for a fast assessment of sarcopenia.

SAT0057 PREDICTING INADEQUATE RESPONSE TO JAK INHIBITORS BY CLUSTER ANALYSIS IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

Oral Janus kinase inhibitors (JAKi) have dramatically altered outcomes in patients with rheumatoid arthritis (RA). However, there remains some proportion of patients who respond to inadequately JAKi treatment (JAKi-IR) [1,2]. The characteristics in RA patients associated with JAKi-IR have not been fully demonstrated.

Objectives:

To clarify the characteristics of JAKi-IR in patients with RA by cluster analysis.

Methods:

This retrospective study comprised 120 RA patients who were treated with JAKi (Tofacitinib or Baricitinib) between July 2013 and September 2019 in five facilities. The disease status at the baseline, at 12 weeks after JAKi treatment and at the time point of withdrawing JAKi was assessed using the Disease Activity Score (DAS28) and the American College of Rheumatology (ACR) response criteria. JAKi-IR was defined as follows, primary non-response at 12 weeks after JAKi treatment: withdrawal of JAKi with ACR20 non-response or non-improvement in DAS28-CRP (ΔDAS28-CRP<1.2 from baseline), secondary non-response: withdrawal of JAKi without clinical remission after 12 weeks. Hierarchical cluster analysis was performed with the following variables: gender, age, disease duration, bone erosion, ACR functional classification (Class ≥3), comcomitant rheumatoid arthritis related interstitial lung disease (RA-ILD) or other autoimmune disease (AID), anti-citrullinated protein antibody (ACPA) positivity, rheumatoid factor (RF) at baseline, use/dose of methotrexate (MTX) and prednisolone (PSL), serum ESR/CRP, tender/swollen joint counts (TJC/SJC), visual analog scale by patients (VAS-Pt), and prior of biologic DMARDs.

Results:

The 120 enrolled patients were classified into 4 groups by cluster analysis(Figure1), The characteristics of each group are as follows, Group A(n=21): female + bone erosion + RF/ACPA positive + AID + MTX non-user, Group B(n=36): male + older age + RA-ILD + RF/ACPA positive + MTX non-user, Group C(n=35): RF/ACPA positive + absence of RA-ILD + MTX user, Group D (n=28): seronegative + MTX user + absence of RA-ILD + history of biologic DMARDs failure. The rate of JAKi-IR was A:9%, B:8%, C:20%, D:32%, and the significant difference between Group B and D was identified (p=0.02). In multiple comparison of 4 groups, no significant difference was identified (p=0.06) (Figure2).

Conclusion:

JAKi-IR would be more likely to be seronegative, MTX use, absence of RA-ILD and history of biologic DMARDs failure. Cluster analysis is an exploratory tool that aids in the analysis of huge amount of data.

References:

[1] Takeuchi T, Yamanaka H, Yamaoka K, Arai S, Toyoizumi S, DeMasi R, et al. Efficacy and safety of tofacitinib in Japanese patients with rheumatoid arthritis by background methotrexate dose: A post hoc analysis of clinical trial data. Mod Rheumatol. 2019;29(5):756-66.

[2] Tanaka Y, Atsumi T, Amano K, Harigai M, Ishii T, Kawaguchi O, et al. Efficacy and safety of baricitinib in Japanese patients with rheumatoid arthritis: Subgroup analyses of four multinational phase 3 randomized trials. Mod Rheumatol. 2018;28(4):583-91.

Disclosure of Interests:

Masanari Sugawara: None declared, Yuichiro Fujieda: None declared, Atsushi Noguchi: None declared, Shun Tanimura: None declared, Yuka Shimizu: None declared, Ikuma Nakagawa: None declared, Michihito Kono: None declared, Masaru Kato: None declared, Kenji Oku: None declared, Tatsuya Atsumi Grant/research support from: Eli Lily Japan K.K., Alexion Pharmaceuticals, Inc., Bristol-Myers Squibb Co., AbbVie Inc., Daiichi Sankyo Co., Ltd., Pfizer Inc., Chugai Pharmaceutical Co., Ltd., Mitsubishi Tanabe Pharma Co., Astellas Pharma Inc., Consultant of: Gilead Sciences, Inc., Eli Lilly Japan K.K., UCB Japan Co. Ltd., AbbVie Inc., Daiichi Sankyo Co., Ltd., Pfizer Inc., Chugai Pharmaceutical Co., Ltd., Speakers bureau: Eli Lilly Japan K.K., UCB Japan Co. Ltd., Bristol-Myers Squibb Co., AbbVie Inc., Eisai Co. Ltd., Otsuka Pharmaceutical Co., Ltd., Daiichi Sankyo Co., Ltd., Pfizer Inc., Chugai Pharmaceutical Co., Ltd., Mitsubishi Tanabe Pharma Co., Takeda Pharmaceutical Co., Ltd., Astellas Pharma Inc.

Fluvastatin prevents the development of arthritis in env-pX rats via up-regulation of Rho GTPase-activating protein 12

The pleiotropic effects of statins, including an antiarthritic potential, have been noted. This study aimed to determine the efficacy of statins on rheumatoid arthritis (RA) and clarify how statins affect its pathogenesis. Fluvastatin (500 μg/kg/day) or vehicle was given per os to env-pX rats, which carry the human T-cell leukemia virus type I env-pX gene and spontaneously develop destructive arthritis mimicking RA, for 30 days. Blood sampling and ultrasonography (US) of the ankle joints were conducted on days 0, 10, 20, and 30. On day 30, all rats were euthanized, and the ankle joints were subjected to histological analysis. To clarify how fluvastatin affects the pathogenesis of RA, comprehensive serum exosomal microRNA (miRNA) analysis was performed. Gene expression in the primary culture of synovial fibroblasts derived from arthritic rat and human and non-arthritic rat periarticular tissues was determined quantitatively by real-time reverse transcription-polymerase chain reaction (RT-PCR). As a result, the development of arthritis in env-pX rats was significantly suppressed by fluvastatin, which was evident from the viewpoints of serology, US imaging, and histology. Comprehensive serum exosomal miRNA analysis suggested that the expression of Rho GTPase-activating protein 12 (Arhgap12) was decreased in arthritic env-pX rats but increased with the administration of fluvastatin. Corresponding results were obtained by quantitative RT- PCR using primary culture of synovial fibroblasts. The collective findings suggest that fluvastatin prevents the development of arthritis in env-pX rats via the up-regulation of ARHGAP12. This study suggests that ARHGAP12 can be a possible therapeutic target of RA.

Detection of Increased Vascular Signal in Arthritis-Prone Rats Without Joint Swelling Using Superb Microvascular Imaging Ultrasonography

This study aimed to determine whether ultrasonography (US) can detect increased vascular signal in the synovial tissue before overt synovitis in rheumatoid arthritis (RA). Env-pX rats that spontaneously develop RA-like synovitis were used. Ankle joints of 15 pre-morbid env-pX rats were observed with power Doppler and superb microvascular imaging (SMI) using an ultrahigh-frequency (8-24 MHz) probe. Signal values were counted as the number of pixels. The total number of vessels and vessel area in the synovial tissue were histologically evaluated. Dilated vessels were determined from the mean value of synovial vessels in three wild-type rats. In all env-pX rats, apparent synovial proliferation was not observed. However, vasodilation was evident. Only SMI values were significantly correlated with the number of dilated vessels (r = 0.585, p = 0.022) but not with the total number of vessels. US with SMI using ultrahigh-frequency probe can detect increased vascular signal in the synovial tissue of arthritis-prone rats.

Detection of Autoreactive Type II NKT Cells: A Pilot Study of Comparison Between Healthy Individuals and Patients with Vasculitis

NKT cells are defined as T cells that recognize hydrophobic antigens presented by class I MHC-like molecules, including CD1d. Among CD1d-restricted NKT cells, type I and type II subsets have been noted. CD1d-restricted type I NKT cells are regarded as pro-inflammatory cells in general. On the contrary, accumulated evidence has demonstrated an anti-inflammatory property of CD1d-restricted type II NKT cells. In our earlier study using a rat model with vasculitis, we demonstrated the pro-inflammatory function of CD1d-restricted type II NKT cells and identified that one such cell recognized P_518-532 of rat sterol carrier protein 2 (rSCP2_518-532 ), which appeared on vascular endothelial cells presented by CD1d. Based on this evidence, we attempted to detect human CD1d-restricted type II NKT cells in peripheral blood using hSCP2_518-532 , the human counterpart of rSCP2_518-532, together with a CD1d tetramer in flow cytometry. First, we determined the binding of hSCP2_518-532 to CD1d. Next, we detected CD3-positive hSCP2_518-532 -loaded CD1d (hSCP2_518-532 /CD1d) tetramer-binding cells in peripheral blood of healthy donors. The abundance of TGF-β-producing cells rather than TNF-α-producing cells in CD3-positive hSCP2_518-532 /CD1d tetramer-binding cells suggests the anti-inflammatory property of SCP2-loaded CD1d (SCP2/CD1d) tetramer-binding type II NKT cells in healthy individuals. Furthermore, we compared cytokine profile between healthy individuals and patients with vasculitis in a pilot study. Interestingly, the percentage of TGF-β-producing cells in SCP2/CD1d tetramer-binding type II NKT cells in vasculitic patients was significantly lower than that in healthy controls despite the greater number of these cells. Although further studies to clarify the mechanism and significance of this phenomenon are needed, SCP2/CD1d tetramer-binding type II NKT cells in peripheral blood should be examined in more detail to understand the pathophysiology of vasculitides in humans. © 2018 International Society for Advancement of Cytometry.

Decreased haptoglobin levels inversely correlated with pulmonary artery pressure in patients with pulmonary arterial hypertension: A cross-sectional study

We investigated the serum haptoglobin levels in patients with pulmonary arterial hypertension (PAH) based on the hypothesis that haptoglobin levels would reflect subclinical hemolysis due to microangiopathy in pulmonary arterioles.This cross-sectional study included 3 groups of patients attending Hokkaido University Hospital: PAH, chronic thromboembolic pulmonary hypertension (CTEPH), and connective tissue diseases (CTD) without PAH (CTD-non-PAH) group. Serum haptoglobin levels were measured by standardized turbidimetric immunoassay in all patients. Demographic data, laboratory results, right heart catheter, and echocardiographic findings were extracted from the medical records. Decreased haptoglobin levels were defined as below 19 mg/dL based on the 95th percentile of healthy controls.Thirty-five patients in PAH group including 11 with idiopathic PAH (IPAH) and 24 with CTD-associated PAH (CTD-PAH), 27 in CTEPH group, and 32 in CTD-non-PAH group were analyzed. Serum haptoglobin levels in PAH group (median 66 mg/dL) were significantly lower than those in CTEPH group (median 94 mg/dL, P = .03) and CTD-non-PAH group (median 79 mg/dL, P = .03). The prevalence of decreased haptoglobin levels was 26% in PAH group, 15% in CTEPH group, and 6% in CTD-non-PAH group. Serum haptoglobin levels had a significant negative correlation (r = -0.66, P < .001) with mean pulmonary artery pressure in PAH group, particularly in CTD-PAH subgroup (r = -0.74, P < .001), but no correlation in IPAH subgroup (r = -0.52, P = .13) and in CTEPH group (r = -0.17, P = .41). Follow-up cases of CTD-PAH showed lowering pulmonary artery pressure led to normalizing serum haptoglobin levels.Serum haptoglobin levels decreased in PAH patients and inversely correlated with pulmonary artery pressure in CTD-PAH patients, suggesting their potential as a surrogate marker for CTD-PAH.

Total Synthesis of Huperzine Q

The total synthesis of huperzine Q was accomplished. The synthesis features the construction of the cis-hydrindane skeleton via a Diels-Alder reaction and a ring contraction reaction of an epoxyketone.

Significance of structural variation in thylakoid membranes in maintaining functional photosystems during reproductive growth

Structural variation in the stroma-grana (SG) arrangement of the thylakoid membranes, such as changes in the thickness of the grana stacks and in the ratio between grana and inter-grana thylakoid, is often observed. Broadly, such alterations are considered acclimation to changes in growth and the environment. However, the relation of thylakoid morphology to plant growth and photosynthesis remains obscure. Here, we report changes in the thylakoid during leaf development under a fixed light condition. Histological studies on the chloroplasts of fresh green Arabidopsis leaves have shown that characteristically shaped thylakoid membranes lacking the inter-grana region, referred to hereafter as isolated-grana (IG), occurred adjacent to highly ordered, large grana layers. This morphology was restored to conventional SG thylakoid membranes with the removal of bolting stems from reproductive plants. Statistical analysis showed a negative correlation between the incidences of IG-type chloroplasts in mesophyll cells and the rates of leaf growth. Fluorescence parameters calculated from pulse-amplitude modulated fluorometry measurements and CO₂ assimilation data showed that the IG thylakoids had a photosynthetic ability that was equivalent to that of the SG thylakoids under moderate light. However, clear differences were observed in the chlorophyll a/b ratio. The IG thylakoids were apparently an acclimated phenotype to the internal condition of source leaves. The idea is supported by the fact that the life span of the IG thylakoids increased significantly in the later developing leaves. In conclusion, the heterogeneous state of thylakoid membranes is likely important in maintaining photosynthesis during the reproductive phase of growth.

[Biomarker of bone and cartilage destruction in rheumatoid arthritis]

Recent progress in treatment and imaging enables us to aim the clinical remission in rheumatoid arthritis. In terms of achieving deep remission (structural remission) and predicting prognosis, useful serological biomarkers are now expected. Recently, some of the serological biomarkers, such as RANKL (receptor activator of NF-κB ligand) and TRACP (tartrate-resistant acid phopshatate)-5b, are used to assess the activity of rheumatoid arthritis. The levels of these biomarkers well reflect bone erosion but are less affected by age or physiological variation.

Instability of Superplastic Aluminium Alloys

The influence of the strain hardening coefficient,γ,and the strain rate sensitivity exponent, m, on the onset and growth of necking has been pointed out in many models about plastic instability controlled by the mechanical properties of materials. In this paper, the instability parameter I (=(l-γ-m)/m) proposed by Hart is used to relate the values of m (=∂lnσ/∂lnέ) and γ (=∂σ/(σ·∂ε)) for some superplastic aluminium alloys. These values of m and γ were calculated from the load-elongation curve at various strain-rates in constant strain-rate tests with periodic m determinations by strain-rate departures of small magnitude. It will be shown that the strain hardening due to grain growth contributes to an increase in the stability of plastic deformation during superplastic flow. However the decrease of m due to dynamic grain growth with strain causes superplastic deformation to be unstable near the onset of fracture. The transition of I values from negative to positive coincides with a decrease in m value and flow stress.

It is concluded that the development of necks can be characterized by an instability parameter I which include the effect of strain hardening caused by strain induced grain growth.

Superplasticity in P/M Aluminium Alloys

Recent advances in the technologies of powder metallurgy lead to the development of some superplastic aluminium alloys containing a deliberate addition of a large amount of Zr and /or Cr and Mn that exhibit the high strain rates superplasticity. For a few alloy systems, the large elongation more than 500% has been observed over the strain rates of 1×10−1s−1, which rates are two or three orders of magnitude faster than those at which superplasticity is found in conventional superplastic aluminium alloys produced by ingot metallurgy. The high strain-rates superplasticity obtained in both type of fully static recrystallized and dynamic recrystallized P/M aluminium alloys. The decreasing of initial size of grains and/or sub-grains leads to the increasing the strain-rates for superplastic flow in both types of alloys. The refinement of grains or sub-grains size is one of necessary and important to obtain the high strain-rates superplasticity.

Epidermolysis bullosa acquisita associated with psoriasis vulgaris

We report a case of epidermolysis bullosa acquisita (EBA) associated with psoriasis vulgaris. A 71-year-old woman with psoriasis vulgaris developed subepidermal blisters on the extremities. Direct immunofluorescence demonstrated linear deposit of IgG at the basement membrane zone, which bound to the dermal side of normal human skin split with 1 mol/L NaCl. Immunoblot analysis using recombinant full-length type VII collagen detected a 290-kDa band, confirming the diagnosis of EBA. A literature search for previous reports found a few cases of EBA associated with psoriasis, and all cases, including our own, presented with widespread inflammatory vesicles and bullae, and responded to conventional therapy with corticosteroids and immunosuppressive agents. This study suggests that western blotting using recombinant full-length type VII collagen could be useful for diagnosis of EBA, and that EBA associated with psoriasis may have a tendency to be the inflammatory type.

Laparoscopic gastrectomy with regional lymph node dissection for upper gastric cancer

BACKGROUND

The technique and results of laparoscopic gastrectomy in 110 patients with gastric cancer located in the upper third of the stomach are presented.

METHODS

Proximal gastrectomy was performed for lesions in the upper third of the stomach, and total gastrectomy for those that spread over both the upper and middle third. D1 and D2 lymph node dissection was undertaken in patients with T1 or T2 lesions. Anastomosis of the oesophagus was performed intracorporeally using a conventional circular stapling device or a laparoscopic linear stapler.

RESULTS

Median operating time was 247 min for proximal gastrectomy and 285 min for total gastrectomy; median blood loss was 207 and 334 ml respectively. A median of 23 lymph nodes was harvested from patients in the proximal gastrectomy group and 34 from those having a total gastrectomy. There was minimal morbidity and fast recovery after surgery. Postoperative recurrence occurred in only one patient, giving a recurrence rate of 0.9 per cent.

CONCLUSION

Laparoscopic gastrectomy for upper gastric cancer appears to be a safe and curative procedure.

Triangulating stapling technique for reconstruction after colectomy

BACKGROUND/AIMS

To retrospectively compare the triangulating stapling technique for colocolonic anastomosis with hand-sewn anastomosis and functional end-to-end anastomosis.

METHODOLOGY

Data from 646 patients who underwent colectomy for cancer from 1993 to 2004 were extracted by chart review. Patients were divided into three groups based on the type of anastomosis: handsewn (n=233), functional end-to-end (n=71), and the triangulating stapling method (n=346). Demographic data and clinical characteristics of the three groups were similar.

RESULTS

Anastomotic leakage was significantly more common in the hand-sewn group than the triangular stapling group (hand-sewn; 3.0%, functional end-to-end; 2.8%, triangulating, 0.6%) (P < 0.05). No patient developed bleeding or stenosis at the anastomosis, and the incidence of wound infection was equivalent among the three groups. One death due to anastomotic failure occurred in each of the functional end-to-end and triangulating stapling groups. The cost of triangulating stapling was approximately Yen 36,000 lower than the cost of the functional end-to-end anastomosis.

CONCLUSIONS

The triangulating stapling technique is an attractive alternative to other methods for creating a colocolonic anastomosis.

Two cases of folliculosebaceous cystic hamartoma

Folliculosebaceous cystic hamartoma (FSCH) is a rare cutaneous hamartoma composed of dilated folliculosebaceous units associated with mesenchymal elements. Two cases of FSCH with typical histopathological features are reported. Patient 1 was a 60-year-old man presented with a normal skin-coloured asymptomatic nodule on his scalp. Patient 2 was a 70-year-old man with an asymptomatic nodule on his right auricle that had persisted for the previous 15 years. In all, 34 cases of FSCH have been reported in the English literature. Clinically, the lesions are asymptomatic, usually rubbery to firm in consistency, and usually occur on or above the neck (> 90%). Most lesions do not exceed 25 mm in diameter (> 90%). Histopathologically, FSCH shares several similar features to sebaceous trichofolliculoma, but it is usually possible to differentiate these two tumours.

[Large malignant mesenchymoma of the left posterior mediastinum; report of a case]

Malignant mesenchymoma is a soft tissue tumor arising preferentially in the extremities and retroperitoneum. We report a case of primary malignant mesenchymoma of the left posterior mediastinum. A 24-year-old woman was admitted to our hospital for complaining of cough. Chest X-ray showed a giant mass occupying the 2/3 of the left hemithorax. Chest computed tomography (CT) revealed a lobulated large mass with fat density area and calcified spot in the mediastinum and left pleural space. Chest magnetic resonance imaging (MRI) demonstrated a large solid mass consisting mainly of areas with the same intensity as fatty tissue and partly of areas with heterogenous moderate intensity. The tumor was resected completely under left posterolateral thoracotomy. The pathologic diagnosis was malignant mesenchymoma; well differentiated liposarcoma with osteocartilagenous differentiation. The patient has been well for 3 years and 3 months after surgery.

[Successful removal of T4 lung cancer with left atrial invasion after induction chemotherapy]

A 53-year-old man presented with cough, sputa and chest pain. The chest X-ray revealed a large mass shadow in the right lower lobe. Massive tumor extending into the left atrium was diagnosed by computed tomography (CT). The brushing cytology by broncoscopy was squamous cell carcinoma and its stage was IIIB. Chemothrapy using cisplatin, paclitaxel and gemcitabine hydrochloride was performed 8 courses during 6 months. The effect of the chemotherapy was complete response, enabling the surgical treatment. The right pneumonectomy with partial resection of the left atrium was performed by using vascular clamp. The defect of the left atrium could be sutured directly. Wide-spread necrotic change with very small amount of cancer cells in the atrial wall was confirmed by pathology. The patient has been well for 3 years and 6 months after surgery.

Laparoscopic distal gastrectomy with regional lymph node dissection for gastric cancer

BACKGROUND

Recent advances in surgical techniques have led to widespread acceptance of laparoscopic gastrectomy for gastric cancer. We performed distal gastrectomy with regional lymph node dissection in 235 patients with gastric cancer located in the middle and lower third of the stomach.

METHODS

In 171 cases, reconstruction was done using the Billroth I method intracorporeally and the aid of laparoscopic linear stapling devices. The Billroth II and Roux-en-Y methods were used in the remaining 56 and eight patients, respectively,

RESULTS

Patients who underwent laparoscopic distal gastrectomy had a more rapid postoperative recovery than those treated via the open approach. Postoperative complications with this technique were within a permissible range. In terms of the survival curve, there was no statistical difference between the laparoscopic group diagnosed as clinical T2N0 (c T2N0) Preoperatively and the open group.

CONCLUSION

The laparoscopic technique is not only less invasive, but is also similarly safe and curative compared to open gastrectomy.

Clear cell sarcoma associated with multiple pulmonary metastases with structural and numerical karyotypic changes

Cytogenetic analysis was performed on a specimen from a pulmonary metastasis of clear cell sarcoma originated on the right ankle of a 53-year-old Japanese woman. It revealed near-triploid with several numerical changes including abnormalities in the copy number of chromosomes 7, 8, and 22, and structural abnormalities of chromosome 22 and others. This is a minor case which showed the multiple abnormalities of chromosomes in the absence of a t (12;22) translocation.

A novel laparoscopic technique for stapled colon and rectal anastomosis

BACKGROUND

We present new techniques of stapling anastomosis at laparoscopic colorectal surgery with retrospective review of data.

METHODS

A triangulating stapling technique (T method) was performed in 101 laparoscopic colectomies. Adouble stapling technique (DST) with rectal division by a conventional linear stapler (Abd method) was used in 5 cases of upper/middle rectal cancers and subsequent eversion of the distal rectum from the anus (Ev method) was used for 4 low rectal cancers. Four hundred ninety-six colectomies and 280 rectal surgeries were reviewed.

RESULTS

Leakage was lower in the T group (0.5%, n=196) than in the hand-sewn group (3.0%, n=233). Leakage of the DST using a laparoscopic linear stapler (12.1%, n=91) was significantly higher than with conventional DST (2.1%, n=189). There was no leakage with either Abd method or Ev method. The T-method is acceptable after laparoscopic colectomy.

CONCLUSION

New methods of rectal division using conventional devices are expected to yield reliable anastomosis at laparoscopic rectal surgery.

Laparoscopic distal gastrectomy with regional lymph node dissection for gastric cancer

Recently, a minimally invasive operation for gastric malignancies has been advocated, and the laparoscopic operation is noted as a technique that increases the quality of life. We performed distal gastrectomy with regional lymph node dissection on 160 cases of gastric cancer located in the middle or lower third of the stomach. In 123 cases, Billroth I reconstruction was performed intracorporeally using the quadrilateral (square) stapling technique with a laparoscopic linear stapling device to prevent postoperative anastomotic bleeding and stenosis. In the remaining 37 cases, the Billroth II method was performed with a linear stapling device [1]. This technique is not only less invasive but also as safe as open gastrectomy, which was performed on 100 gastric cancer cases of similar staging.

[A study of thymoma associated with cancer of the other organs]

Out of 97 cases of thymoma for the last 20 years, we have experienced 7 cases (9%) of thymoma associated with cancer of the other organs. The average age of the 7 cases was 60 years old and there were 3 females and 4 males. The organ with cancer was stomach in 3 cases, thyroid in 2, and lung, breast, colon and leukemia in one respectively. Histological classification of 8 thymomas in 7 cases was 3 epithelial type, 2 lymphocytic type and 3 mixed type. Myasthenia gravis with thymoma was only one out of them. we have to follow up carefully the patient with thymoma about occurrence of cancer of the other organs without thymus for a long time.

[Basaloid carcinoma originated from the wall of thymic cyst presenting as pericardial and thoracic effusion; report of a case]

We report a case of basaloid carcinoma originated from the wall of a large thymic cyst, which is a very rare subtype of thymic carcinoma. A 60-year-old man admitted at our hospital due to dyspnea with pericardial and left thoracic effusion on chest X-ray. A computed tomography and a magnetic resonance imaging demonstrated a large anterior mediastinal cyst and a small mass lesion on the part of the wall. We performed as possible as resection of the thymic cyst and the tumor with median sternotomy. The pathological diagnosis was a thymic basaloid carcinoma originated from the wall of a thymic cyst, which classified into a low-grade histology in thymic carcinoma. He has been well with no evidence of recurrence for three years since operation followed by a post-operative radiation therapy (total 57 Gy) to the residual tumor and mediastinum.

[Surgical treatment for bilateral multiple lung cancers]

We reviewed 21 patients with bilateral multiple bronchogenic carcinomas. Eleven of them had synchronous carcinomas and 10 had metachronous carcinomas. We treated 6 patients with lobectomy and wedge resection under median sternotomy synchronously, and 2 patients with lobectomy on both lungs under standard thoracotomy, 2 patients with lobectomy and wedge resection, 1 patient with segmentectomy on both lung, 1 patient with lobectomy and segmentectomy, 1 patient with pneumonectomy and wedge resection, and 8 patients with lobectomy and thoracoscopic wedge resection on each lung metachronously. Two patients who had lobectomy on both lungs were dead, one of whom of pulmonary edema 2 weeks after second operation and the other of respiratory failure 3 years after second operation. We concluded that lobectomy on both lungs are not recommended because of high mortality rate (10%) and the limited resection under thoracoscopic surgery should be considered to treat the other contra lateral primary lung cancers.

ERK pathway positively regulates the expression of Sprouty genes

Sprouty was originally identified as an inhibitor of Drosophila development-associated receptor tyrosine kinase (RTK) signaling. Although RTK signaling has been shown to induce Sprouty gene expression, the precise induction pathway downstream of RTK remains unclear. As RTK signaling pathway includes activation of extracellular signal-regulated kinases (ERKs), we have examined a correlation between activation of ERKs and induction of Sprouty gene expression. All reagents which induce the activation of ERKs induce Sprouty gene expression; these agents include not only growth factors which bind to RTK but also phorbol 12-myristate-13-acetate and active Raf-1 kinase. Furthermore, the Sprouty gene expression induced by all those agents is totally suppressed when the cells are pretreated with specific inhibitors of ERK kinase (MEK). Human tumor cells which exhibit constitutive activation of ERKs show elevated expression of Sprouty genes, which is abolished by treatment of these cells with MEK inhibitors. All these findings clearly indicate that Sprouty gene expression is positively regulated by the ERK pathway downstream of RTK.

Laparoscopy-assisted resection for jejunal carcinoma

Laparoscopic surgery has been applied in small bowel resections for various diseases, such as obstruction including intussusception, diverticula, and tumors. We report a case of successful resection of a jejunal carcinoma that was diagnosed before surgery by using a laparoscopy-assisted technique.

Hand-assisted laparoscopic distal gastrectomy with regional lymph node dissection for gastric cancer

Recently, a minimally invasive operation for gastric malignancies has been advocated, and the laparoscopic operation is noted as a technique that raises the quality of life. We performed distal gastrectomy with regional lymph node dissection by hand-assisted laparoscopic surgery for 60 cases of gastric cancer located in the middle or lower third of the stomach. Billroth I reconstruction was applied intracorporeally to the first 30 cases by using the double stapling method with a conventional circular stapling device, and in the final 30 cases, the quadrilateral (square) stapling technique with a laparoscopic linear stapling device was used to prevent postoperative anastomotic bleeding. This technique not only is less invasive, but also is similarly curative compared with open gastrectomy that was performed for 60 gastric cancer cases of similar staging before the beginning of this procedure.

[A case of benign schwannoma arising in the brachial plexus with intrathoracic extension]

A case of benign schwannoma originating from the lowest trunk of the left brachial plexus with intrathoracic extension was reported. Intrathoracic growth of a schwannoma of the brachial plexus has been reported in only five cases in the literature. The patient was a 35-year-old man and had been pointed out an abnormal shadow at the left lung apex on the roentgenogram since 20-year-old. The tumor shadow was increased to seven cm from four in size on recent chest X-ray. We performed a video-assisted thoracoscopic surgery with the oblique skin incision at the left neck and removed the tumor completely and safely.