Neural-net-based cell deconvolution from DNA methylation reveals tumor microenvironment associated with cancer prognosis

DNA methylation is a pivotal epigenetic modification that defines cellular identity. While cell deconvolution utilizing this information is considered useful for clinical practice, current methods for deconvolution are limited in their accuracy and resolution. In this study, we collected DNA methylation data from 945 human samples derived from various tissues and tumor-infiltrating immune cells and trained a neural network model with them. The model, termed MEnet, predicted abundance of cell population together with the detailed immune cell status from bulk DNA methylation data, and showed consistency to those of flow cytometry and histochemistry. MEnet was superior to the existing methods in the accuracy, speed, and detectable cell diversity, and could be applicable for peripheral blood, tumors, cell-free DNA, and formalin-fixed paraffin-embedded sections. Furthermore, by applying MEnet to 72 intrahepatic cholangiocarcinoma samples, we identified immune cell profiles associated with cancer prognosis. We believe that cell deconvolution by MEnet has the potential for use in clinical settings.

Development of a new gastrointestinal endoscope forceps plug that can minimize gas leakage

Background and aims

In our previous study, we visualized and systematically evaluated gas leakage from the forceps plug of the gastrointestinal endoscope system using the Schlieren system. In order to minimize the potential risk of infection from gas leakage from the gastrointestinal endoscope, the development of a new forceps plug was considered urgent. In this study, we analyzed the structure of commercially available forceps plugs and attempted to develop new forceps plugs with improvements.

Methods

Microfocus computed tomography was used to nondestructively analyze the structural changes that occur when forceps are inserted into a commercially available forceps plug. Based on the findings, the basic structure of the newly developed forceps plug was set. We examined the airtightness of these newly developed plugs using the Schlieren system and also compared their fractional resistance with those of commercially available plugs.

Results

As a result of the nondestructive analysis, all of the commercially available plugs had a single valve, and the cleavage created in the valve during forceps, insertion was large in the case of plugs with slit-type entrances. In the newly developed forceps plugs, all four types of plugs showed less gas leakage and similar or better usability compared to the commercially available plugs.

Conclusions

The structural weaknesses of the existing gastrointestinal endoscopic forceps plugs were identified. Based on the findings, we froze the design of a prototype of a new forceps plug that was airtight and not inferior in usability compared to commercially available plugs.

Use of current automatic smoke evacuation system in flexible gastrointestinal endoscopy: Its feasibility and potential usefulness

Objectives

Flexible endoscopy does not have a system that can automatically evacuate surgical smoke generated in the gastrointestinal lumen. We aimed to investigate the feasibility and potential usefulness of automatic smoke evacuation systems in flexible endoscopy.

Methods

[Bench] After surgical smoke generated in the stomach was evacuated by the evacuator, the degree of residual smoke and gastric luminal collapse were evaluated to optimize the evacuator settings. [Animal] Insufflation, suction, and total operation time to complete the protocol of 10 cauterizations of the gastric mucosa were measured in three groups: "manual suction only," "manual suction with automatic evacuation (50% force)," and "manual suction with automatic evacuation (70% force)." The stability of endoscopic visualization and operability was evaluated by 10 endoscopists blinded to those suction settings, and the number of manual suctions, insufflations, and total operation time were measured.

Results

[Bench] The degree of residual smoke and gastric luminal collapse were inversely correlated. [Animal] When the automatic evacuator was partially used, there was no difference in the insufflation time, but the suction time (vs 50%; p = 0.011, vs. 70%; p = 0.011) and total operation time (vs. 50%; p = 0.012, vs. 70%; p = 0.036) were significantly reduced compared to manual operation only. Furthermore, manual suction with automatic evacuation (50% force) significantly improved the stability of endoscopic visualization and operability compared to manual operation only (p = 0.041, p = 0.0085).

Conclusions

The automatic smoke evacuation in flexible gastrointestinal endoscopy was potentially feasible and useful by improving the device setting.

Serum NY-ESO-1 and p53 antibodies as useful tumor markers in gastric cancer

Purpose

The NY-ESO-1 antigen is highly immunogenic and often spontaneously induces an immune response in patients with cancer. We conducted a large-scale multicenter cohort study to investigate the utility of serum NY-ESO-1 and p53 antibodies as predictive markers for the postoperative recurrence of gastric cancer. Here, we examined the usefulness of pre-treatment NY-ESO-1 and p53 antibodies as tumor markers for the diagnosis of gastric cancer in combination with carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9).

Methods

A total of 1031 patients with cT3-4 gastric cancer were enrolled in the study. NY-ESO-1 and p53 antibodies were assessed prior to treatment. The positivity of NY-ESO-1 and p53 antibodies, CEA, and CA19-9 was evaluated before treatment.

Results

Serum NY-ESO-1 and p53 antibodies were positive in 12.6% and 18.1% of the patients, respectively. Positive NY-ESO-1 antibody response was correlated with male gender, higher cStage, and upper tumor location. However, a positive p53 antibody response was not associated with tumor factors. The combination of NY-ESO-1 or p53 antibody response with CEA and CA19-9, or the 4-factors, was positive in 45.1%, 49.6%, and 53.8% of patients, respectively. Moreover, the 4-factor combination was able to detect >60% of cStage III-IV diseases, which was 14% higher than that with the combination of CEA and CA19-9.

Conclusion

The combination of NY-ESO-1 and p53 antibody responses to CEA and CA19-9 increases the diagnostic accuracy of gastric cancer. Serum NY-ESO-1 and p53 antibodies may be useful tumor markers for gastric cancer.

Gemcitabine and cisplatin plus nivolumab as organ-sparing treatment for muscle-invasive bladder cancer: a phase 2 trial

Cystectomy is a standard treatment for muscle-invasive bladder cancer (MIBC), but it is life-altering. We initiated a phase 2 study in which patients with MIBC received four cycles of gemcitabine, cisplatin, plus nivolumab followed by clinical restaging. Patients achieving a clinical complete response (cCR) could proceed without cystectomy. The co-primary objectives were to assess the cCR rate and the positive predictive value of cCR for a composite outcome: 2-year metastasis-free survival in patients forgoing immediate cystectomy or Collapse

Key Words

• phase ii trials
• translational research
• bladder cancer
• cancer immunotherapy
• chemotherapy

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MESH Headings

• Humans
• Antineoplastic Combined Chemotherapy Protocols/therapeutic use
• Cisplatin/therapeutic use
• Deoxycytidine/therapeutic use
• Disease-Free Survival
• Gemcitabine
• Muscles
• Neoadjuvant Therapy
• Neoplasm Invasiveness
• Nivolumab/therapeutic use
• Urinary Bladder Neoplasms/drug therapy
• Urinary Bladder Neoplasms/pathology
• Xeroderma Pigmentosum Group D Protein

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Grants

• U24 CA224319 NCI NIH HHS
• U01 DK124165 NIDDK NIH HHS
• U24 CA224316 NCI NIH HHS
• U24 CA224285 NCI NIH HHS
• T32 CA078207 NCI NIH HHS
• P30 CA196521 NCI NIH HHS
• U24 CA224331 NCI NIH HHS
• R01 CA249175 NCI NIH HHS
• V Foundation for Cancer Research (V Foundation)
• Bristol-Myers Squibb (Bristol-Myers Squibb Company)
• U.S. Department of Health & Human Services | NIH | National Cancer Institute (NCI)
• Foundation for the National Institutes of Health (FNIH)/Partnership for Accelerating Cancer Therapies (PACT)

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A novel, simple, and dedicated device for endoscopic mucosal defect closure

OBJECTIVES

Endoscopic submucosal dissection (ESD) has become popular, but complications such as postoperative bleeding remain an issue. Although some methods of closing a mucosal defect with a snare and clips have been reported to be effective and safe, the snare is not a dedicated device, and the procedure is difficult and time-consuming. We aimed to find an alternative method for defect closure after ESD by developing a dedicated device.

METHODS

We have improved five prototypes. The load on the stopper when starting to tighten and loosen a loop and the maximum load on the stopper and the movement distance of the thread when sliding the stopper were measured five times for each prototype. With the 5th prototype, we finalized the design and named it FLEXLOOP. Additionally, the material and shape of the outer tube were improved. Then, the usability of FLEXLOOP was evaluated in pigs. The operation time for closing mucosal defects with the snare or FLEXLOOP was measured five times.

RESULTS

We made FLEXLOOP, which had a lower load when sliding and a higher load when loosening than the snare. The improvement of the outer tube significantly reduced the load on the sheath when sliding it. We confirmed the feasibility of mucosal defect closure with FLEXLOOP in pigs. The median operation time was 563 s (range 340-679 s) with the snare and 355 s (range 303-455 s) with FLEXLOOP (p = 0.047).

CONCLUSIONS

FLEXLOOP can be a promising option for defect closure after ESD.

Neutropenia is an indicator of outcomes in metastatic colorectal cancer patients treated with FTD/TPI plus bevacizumab: a retrospective study

PURPOSE

Trifluridine/tipiracil (FTD/TPI) improves the overall survival (OS) of metastatic colorectal cancer (mCRC) patients. Additionally, FTD/TPI plus bevacizumab (BEV) has demonstrated promising efficacy for mCRC patients who are refractory to standard chemotherapy. Chemotherapy-induced neutropenia (CIN) has been reported to be an indicator of efficacy for FTD/TPI. This study investigated whether CIN was an indicator of efficacy for FTD/TPI plus BEV.

METHODS

We reviewed chemo-refractory mCRC patients who were treated with FTD/TPI alone (monotherapy) or FTD/TPI plus BEV (combination) at our institution and compared the safety and efficacy of the two. Progression-free survival (PFS) and OS were analyzed using Kaplan-Meier curves. We also investigated correlations between CIN and outcomes.

RESULTS

In total, 56 patients received FTD/TPI, among whom 24 and 32 were treated with monotherapy and combination therapy, respectively. The median PFS was 1.8 and 4.7 months for the monotherapy and combination arms, respectively (hazard ratio [HR]: 0.28; 95% confidence interval [CI]: 0.15-0.51; P < 0.001). The median OS was 6.3 and 11.7 months for the monotherapy and combination arms, respectively (HR 0.25; 95% CI 0.13-0.48; P < 0.001). CIN (Grade 3 or worse) developed in five (20.8%) and 17 (53.1%) patients from the monotherapy and combination arms, respectively (P = 0.030). Patients with CIN in the combination arm had improved PFS and OS compared with non-CIN patients (P = 0.033 and P = 0.045, respectively).

CONCLUSIONS

FTD/TPI plus BEV prolonged PFS and OS and had tolerable toxicity compared with FTD/TPI alone. CIN is an indicator of patients who will benefit from FTD/TPI plus BEV.

[Long-Term Survival in a Patient with Stage Ⅳ Gastric Cancer Successfully Treated with Multidisplinary Treatment]

A man in his 60s who had epigastric pain was referred to our hospital and diagnosed with advanced type 3 gastric cancer with multiple liver metastases, cT4acN2cN1(H1), cStage Ⅳ(HER2 3+). He underwent chemotherapy using capecitabine, cisplatin(CDDP), and trastuzumab(T-mab)(XPT). After 7 courses of XPT and 23 courses of XT, liver metastases disappeared, and we decided to perform open distal gastrectomy, D2+ #18 lymphadenectomy, and Billroth Ⅰ reconstruction as a conversion surgery. Despite adjuvant chemotherapy with S-1 plus T-mab, multiple lymph nodes recurrence occurred 3 months after the surgery. He was found to be in complete remission as assessed by CT after 5 courses of second-line CPT-11 treatment, which was discontinued after 17 courses. The patient is alive without recurrence at 57 months after the initial treatment and 22 months after the last treatment.

[A Case of Robot-Assisted Abdominoperineal Resection for Local Control for Lower Rectal Cancer with Synchronous Liver and Lung Metastases]

The patient was a 70s woman who was referred to our hospital with a complaint of bloody stool. Colonoscopy revealed type 2 tumor at a distance of 1 cm from the dentate line, without obstruction. The pathological diagnosis was adenocarcinoma. Enhanced CT revealed a tumor at the rectum below peritoneal reflection as well as swelling of the mesorectal lymph nodes. Multiple liver and lung metastases were also observed. The diagnosis was lower rectal cancer cT4aN2M1b(H2, PUL2), cStage Ⅳ. Chemotherapy was performed for disease control because of unresectable metastases. She received 7 courses of mFOLFOX plus bevacizumab. Further, as the metastatic lesion was inhibited, the primary lesion was excised for the purpose of symptom control. We judged that sphincter preservation was impossible because it was 1 cm away from the dentate line. She underwent robot-assisted abdominoperineal resection with D3 lymphadenectomy and sigmoid colostomy.

[A Resected Case of Hepatocellular Carcinoma Recurrence with Bile Duct Tumor Thrombus after RFA]

Hepatocellular carcinoma with bile duct invasion is rare, with a reported incidence of 3.4%. A 71-year-old man with hepatocellular carcinoma underwent radiofrequency ablation(RFA)(S6, S7, S8)and required readmission 22 months after the RFA for hepatocellular carcinoma recurrence detected by gadoxetic acid-enhanced magnetic resonance imaging. Enhanced abdominal computed tomography and magnetic resonance cholangiopancreatography revealed a tumor thrombus in a biliary branch and left adrenal gland metastases. We performed a right lobectomy and left adrenalectomy. The biliary thrombus was easily removed. Postoperative histopathological examination of the resected specimen showed a moderately differentiated hepatocellular carcinoma invading the biliary tract and the absence of viable cells in the liver tumor. The patient has shown no recurrence 6 months after the hepatectomy.

Safety and efficacy of trifluridine/tipiracil (FTD/TPI) plus bevacizumab in clinical practice for patients with chemorefractory metastatic colorectal cancer: A retrospective comparative study

112

Background: Trifluridine/tipiracil (FTD/TPI) significantly improves overall survival (OS) in patients with chemorefractory metastatic colorectal cancer (mCRC). The phase I/II C-TASKFORCE study of FTD/TPI + bevacizumab (Bev) for patients with mCRC who are refractory to standard chemotherapy demonstrated promising efficacy results. FTD/TPI + Bev were linked to significant and clinically relevant improvements in progression-free survival (PFS) and OS compared with FTD/TPI monotherapy and a favorable safety profile in a Danish randomized trial. This retrospective study investigated the safety and efficacy of FTD/TPI alone or in combination with Bev for patients with refractory mCRC in clinical practice. Methods: We reviewed the outcomes of patients with chemorefractory mCRC who received FTD/TPI alone (monotherapy; 35 mg/m2, twice daily on days 1–5 and 8–12 in a 28-day cycle) or FTD/TPI + Bev (combination; 5 mg/kg, days 1 and 15) in our institution since 2014. We compared the safety and efficacy of the monotherapy and combination regimens. Adverse events were evaluated using Common Terminology Criteria for Adverse Eventsv4.0. Median PFS and OS were analyzed using the Kaplan–Meier method. Results: In total, 56 patients received chemotherapy containing FTD/TPI. Twenty-four patients were treated with monotherapy, and 32 patients received the combination regimen. The median PFS was 1.8 months in the monotherapy arm, versus 4.7 months in the combination arm (hazard ratio [HR] = 0.28; 95% confidence interval [CI] = 0.15–0.51; P < 0.0001). The median OS was 6.3 months for the monotherapy arm, versus 11.7 months for the combination arm (HR = 0.25; 95% CI = 0.13–0.48; P < 0.0001). There was no significant difference in the rates of adverse events between the groups excluding neutropenia. Neutropenia (Grade 3 or worse) developed in five patients (20.8%) in the monotherapy arm and 17 patients (53.1%) in the combination arm ( P = 0.030). There were no treatment-related deaths. Conclusions: In patients with chemorefractory mCRC, FTD/TPI + Bev significantly improved PFS and OS versus FTD/TPI monotherapy.

Safety of tapering tacrolimus dose in patients with well-controlled anti-acetylcholine receptor antibody-positive myasthenia gravis

BACKGROUND AND PURPOSE

Tapering immunosuppressants is desirable in patients with well-controlled myasthenia gravis (MG). However, the association between tapering of calcineurin inhibitor dosage and reduction-associated exacerbation is not known. The aim of this study was to clarify the frequency of reduction-associated exacerbation when tacrolimus is tapered in stable patients with anti-acetylcholine receptor antibody-positive MG, and to determine the factors that predict exacerbations.

METHODS

We retrospectively analyzed 115 patients in whom tacrolimus dosage was tapered. The reduction-associated exacerbation was defined as the appearance or worsening of one or more MG symptoms <3 months after the reduction.

RESULTS

Tacrolimus dosage was successfully tapered in 110 patients (96%) without any exacerbation. Five patients (4%) experienced an exacerbation, but symptoms were reversed in all patients when the tacrolimus dose was increased to the previous maintenance level. No patient developed an MG crisis. The age at onset was significantly earlier (30 vs. 56 years, P = 0.025) and the reduction in dosage was significantly larger (2.0 vs. 1.0 mg/day, P = 0.002) in patients with reduction-associated exacerbation than in those without exacerbation. The cut-off values determined in a receiver-operating characteristic curve analysis were 52 years (sensitivity, 57%; specificity, 100%) for the age at onset and 1.5 mg (sensitivity, 80%; specificity, 100%) for the dose reduction.

CONCLUSION

Tapering of tacrolimus was possible in most patients with well-controlled anti-acetylcholine receptor antibody-positive MG. Early age at onset and a large reduction from maintenance dosage were associated with exacerbation. Reductions ≤1.5 mg/day from the maintenance dosage should be considered for patients with late-onset disease.

[A Case of Leiomyosarcoma of the Sigmoidal Mesocolon]

Leiomyosarcoma of the mesocolon is a very rare disease. Previously, there was no recommendation for chemotherapy or radiotherapy for leiomyosarcoma of the mesocolon, and only surgical resection reportedly offers a chance for cure. However, the reported cases of leiomyosarcoma of the mesocolon were not distinguished from those of gastrointestinal stromal tumor (GIST), which is the same mesenchymal tumor; thus, there is a possibility that they include cases that should be diagnosed as GIST. We report a case of leiomyosarcoma of the sigmoidal mesocolon.

[Sustained Complete Response of Hepatocellular Carcinoma with Multiple Intrahepatic Metastases following the Discontinuation of Sorafenib]

Sorafenib is an oral multi-targeted tyrosine kinase inhibitor used in cases of unresectable advanced HCC that significantly improves progression-free and overall survival. Complete response(CR)is uncommon; however, if major or complete radiological response are obtained, the issue of the discontinuation of sorafenib remains unresolved. The present study reported a case of a 75-year-old man with non-hepatitis B and C virus-related cirrhosis and multiple recurrent HCCs followingresection. In December 2010, a CT scan revealed multiple intrahepatic recurrence after TACE. Laboratory testingshowed Child-Pugh class A cirrhosis and an alpha-fetoprotein level of over 20,000 ng/mL. Sorafenib(800mg/day)was started in December 2010. The subsequent dynamic CT performed at the 6th month of therapy showed a partial response accordingto RECIST criteria and a complete response accordingto mRECIST. The AFP had decreased to within normal levels. In May 2012, the sorafenib dose was reduced(200 mgtwice daily)due to side effects(skin reaction). In December 2013, treatment was stopped after confirmation of a CR associated with shrinkage of the HCC. The patient maintained this remission until June 2018, more than 54 months after the discontinuation of sorafenib therapy. The adverse events of sorafenib were reversible. Further reportingof similar cases should help in the design of treatment strategies after CR to sorafenib therapy.

[A Resected Case of Tumorigenic Pancreatic Endocrine Cell Hyperplasia]

A 51-year-old man with a gallstone was found to have a tumor in the tail of the pancreas during preoperative examination. We performed EUS-FNA and a pancreatic neuroendocrine tumor was suspected.Therefore, laparoscopic distal pancreatectomy and cholecystectomy were performed.Pathological examination and immunohistochemistry showed that the pancreatic endocrine cells were uniformly increased and were composed of normal Langerhans islets.Therefore, the patient was diagnosed with pancreatic endocrine cell hyperplasia.Typical pancreatic endocrine cell hyperplasia does not form a tumor and is asymptomatic.However, some cases are symptomatic; therefore, when hypoglycemia or pancreatic hormone elevation are found without a clear cause, it should be distinguished.Because pancreatic tumors are difficult to diagnose definitely by imaging inspection alone, needle biopsy is necessary.However, neuroendocrine tumor and neuroendocrine cell hyperplasia are difficult to differentiate by biopsy.

Long-term outcomes of surgical resection of lung metastases from colorectal cancer

655

Background: The lungs are one of the most frequent sites of metastases from colorectal cancer(CRC). Surgical resection has been widely performed on patients with pulmonary metastases from CRC with favorable outcomes. Surgical treatment is considered an effective option, but the surgical indications of lung resection have institutional bias. In our hospital, we aggressively perform surgery for lung metastases when the primary tumor and other metastases are controlled and all lung metastases are resectable. In this study, the aim is to investigate the long-term outcomes of resections of lung metastases from CRC in our institute. Methods: Between April 2009 and November 2017, patients who underwent lung resections for metastases from CRC with curative intent in our hospital were investigated retrospectively. Kaplan-Meier survival curves, log-rank tests, chi-squared test and T-test were used to analyze the survival rates and the factors predicting recurrence. Results: Sixty-seven patients underwent lung resection of metastases from CRC. The median follow-up period was 25.3 (6-60) months. Five-year disease free survival was 33.6 % and 5-year overall survival was 63.9%. Because of pulmonary recurrence, second surgery was performed in 16 patients and a third surgery in three patients. 5-year overall survival rate after first lung resection in patients who underwent repeated lung resection was 49.2%. There was no significant difference between the number of patients with pulmonary recurrence and those with no recurrence after lung resection (p = 0.38). Twenty-one patients had experienced prior liver resection; the 5-year overall survival rate after lung resection in these patients was 57.9 %. Factors predicting recurrence were vascular invasion (v ≥ 2) of primary tumor (p = 0.02), pre-operative serum CEA (p = 0.03) and CA-19-9 (p = 0.04). Conclusions: The outcome of lung resection of metastases from CRC in our hospital was satisfactory. Aggressive lung resection for cases even after liver resection and repeated pulmonary recurrence may improve long-term outcomes.Vascular invasion of primary tumor and the pre-operative serum CEA and CA 19-9 level can be predictive markers for recurrence.

[A Case of Strangulating Intestinal Obstruction Caused by Coiling of Low-Grade Appendiceal Mucinous Neoplasm to Terminal Ileum]

The patient was a 67-year-old female without a history of surgery. She presented with an abdominal pain and vomiting, and was rushed to our hospital. The abdominal pain was severe, but no peritoneal irritation sign was observed. Abdominal CT scan revealed a strangulating intestinal obstruction and accumulation of ascitic fluid. Emergency surgery was performed for diagnosis and treatment. The intraoperative finding showed serous ascitic fluid and strangulating intestinal obstruction caused by appendiceal tumor coiling around the terminal ileum, which had become ischemic with thinning of its wall. Ileocecal resection with removal of lymph nodes(D3)was performed. The postoperative course was uneventful, and the patient was discharged 13 days after the surgery. Pathological examination of the appendiceal tumor revealed a low-grade appendiceal mucinous neoplasm(LAMN)with no metastasis to the lymph nodes. We had a rare case of strangulating intestinal obstruction caused by coiling of LAMN to the terminal ileum.

[A Case of Gastric Schwannoma with Regional Lymphadenopathy]

Schwannomas are rarely observed in the gastrointestinal tract. A 63-year-old man was referred to our hospital with gastric submucosal tumor with central ulceration by upper gastrointestinal endoscopy. Biopsy was performed, but pathological diagnosis was not obtained. A contrast-enhanced computed tomography scan of the abdomen revealed a round mass in the lower part of the stomach and regional lymphadenopathies. A distal gastrectomy with dissection of the regional lymph nodes (D2)was performed. The submucosal tumor measuring 67×49mm was resected. Histopathological examination revealed spindle-shaped cells arranged in palisades. The specimen was positive for S-100 protein, but negative for desmin, SMA, c-kit, and CD34. No tumor cells were found in the resected enlarged lymph nodes, indicating reactive lymphadenopathies. Based on these findings, the tumor was identified as a benign gastric schwannoma. Our patient shows no recurrence at 6 month follow-up.

[Treatment Outcomes of Gemcitabine and Cisplatin Combination Therapy for Unresectable and Recurrent Biliary Tract Cancer]

Gemcitabine and cisplatin combination therapy(GC therapy)is now considered a highly effective regimen for patients with unresectable and metastatic biliary tract cancer. We performed GC therapy for 18 patients between January 2014 and April 2018. The median age of the patients was 67.5 years, and 13 patients were men. Fifteen patients had a performance status (PS)score of 0, and 3 patients had a PS score of 1. Nine patients had distal cholangiocarcinoma, 3 had intrahepatic cholangiocarcinoma, 3 had duodenum papilla cancer, and 3 had gallbladder cancer. Fourteen patients showed recurrence after the radical resection, and 9 had liver metastasis. Sixteen patients had over Grade 3 hematological or non-hematological toxicities. The most-common adverse event was neutropenia. None of the patients had Grade 5 adverse events. The response rate was 11.1%, and the disease-control ratio was 66.7%. GC therapy was effective for patients with unresectable and recurrent biliary tract cancer. However, it is necessary to examine the eligibility of patients before treatment.

Radionuclide Assessment of the Natural Heart Ejection Fraction before and after LVAD Implantation

Complete pressure unloading of the ventricles can preserve ischemically damaged myocardium. Most clinical left heart assist device (LVAD) systems used after ischemic injury of the heart apply atrial cannulation which does not ensure pressure unloading. In order to assess the effect of the implantation of an intracorporeal LVAD on the function of the natural heart, we determined the ejection fraction (EF) in four male Holstein calves (90–105 kg) before and after insertion of a Cleveland Clinic pneumatic LVAD. A gated blood pool scan was obtained with a gamma camera after injection of 40 mCi Tc-labelled albumin. The animals were restrained in a sling to avoid movement artifacts.

All animals showed a drop of 65 ± 12% to 42 ± 14% EF in the first postoperative (p.o.) week. Left ventricular output did not maintain sufficient blood pressure as assessed by pump-off tests. Systolic blood pressure dropped from 122 ±6.5 mm Hg to 81 ± 6 mm Hg without pump support on the morning of the first p.o. day.

Apical coring and possible restrained heart movement by the implanted LVAD may lead to impaired myocardial function that renders the individual LVAD dependent until adaptative corrections take place.

Blood Detoxification by Membrane Plasma Filtration

The recognition of macromolecule abnormalities in various metabolic or immunologic related disease states has led to the use of plasma exchange for therapeutics. Limitations of plasma exchange, however, exist. Membrane plasma filtration provides a practical alternative. Solute removal can be made selective by the choice of operating conditions as temperature and the selection of the membrane/module design. The optimal temperature range is a function of the plasma type, solute concentrations and membrane system. Operation at below physiologic temperature (cryofiltration) is particularly suited for the removal of cold aggregative solutes, while operation at near or above physiologic temperature is more suited for the separation of solutes having large size differences at normal physiologic temperature. Membrane filtration is simple and safe to perform, is more selective than plasma exchange, does not require plasma product infusion and is more versatile than selective sorption in its applications.

[A Case of Laparoscopic Rectal Amputation Performed for Anal Gland Mucinous Carcinoma with Pagetoid Spread]

A 69-year-old man was admitted for the growing anal tumor and referred to our hospital. The tumor was about 40mm in size, and by biopsy, he was diagnosed the adenocarcinoma. Based on this diagnosis, abdominoperinealresection and edge resection were performed. Histopathologicalfindings showed mucinous carcinoma originating from analgl and with pagetoid spread. Postoperative chemotherapy was not performed, but 1 year 6 months after the surgery, inguinall ymph node recurrence was found, and lymph node dissection was performed. One year after the operation, recurrence was not found.

Patient Registration and Treatment Allocation in Multicenter Clinical Trials Using a FAX-OCR System

This article describes the design and results of implementation of an automated patient registration and freatment allocation system (RETAS) used in multicenter clinical trials. RETAS was developed using a FAX-OCR system by which handwritten Japanese and English characters, as well as numericals and forms with check boxes, are sent from participating institutions by Fax, processed using an optical character reader, and then transmitted to a host computer at a statistical center. Based on the facsimile data, RETAS can automatically review eligibility, collect patient identification data and provide a randomized treatment allocation. RETAS permits uninterrupted, unattended operation at a statistical center, 24 hours a day, 7 days a week. Therefore, it drastically decreases the workload of personnel at the statistical center needed to support central telephone registration coverage. Consequently, staff members are free to focus on patient registration, treatment allocation, and follow-up of patients. The treatment allocation procedure in this system is based on Pocock and Simon’s minimization method combined with Zelen’s method for institution balancing. By this system it was possible to balance treatment numbers for each level of various prognostic factors over an entire trial and, at the same time, balance the allocation of treatments within an institution. The system currently supports the protocol of a clinical trial for Adjuvant Chemo-Endocrine Therapy for Breast Cancer in West Japan.

Laparoscopic resection followed by decompression with a drainage tube for obstructive colorectal cancer

844

Background: Obstructive colorectal cancer is an oncological emergency that requires emergency treatment. In Japan, laparoscopic resection after decompression with metallic-stent placement is becoming mainstream as a bridge to surgery (BTS). However, there are reports of worse prognoses due to stent placement, and the European Gastroenterology Society of Endoscopy guidelines do not recommend BTS. In our department, since 2011 the first choice of the treatment has been laparoscopic resection after decompression with a trans-anal or trans-nasal drainage tube. STo investigate the safety and short- and long-term results of laparoscopic resection after decompression with a drainage tube. Methods: Eighty-one cases of obstructive colorectal cancer that underwent surgery at our hospital from 2011 to 2016 were investigated with regards to the short- and long-term outcomes of treatment strategies for obstructive colorectal cancer. Results: The median age was 72 years old (39-94). The ratio of male to female was 46:29. The success rate of decompression was 86.7% (66 cases). Stages II, III and IV were involved in 25, 28 and 28 cases, respectively. The causes of the emergency operations were an inability to insert both the ileus tube and the stent (9.3%, 7 cases), and perforation (2.7%, 2 cases) when the trans-anal ileus tube was inserted. In the cases in which decompression was possible, the laparoscopic operation rate was 89.4% (56 cases) and the primary resection rate was 90.9% (59 cases). The median surgical time was 194 minutes (27-325), the median blood loss was 10 g (0-660 g),The median postoperative hospital stay was 14 days (5-147 days). The rate of anastomotic leak was 4.5%. There were no deaths within 30 and 90 days after surgery. The relapse free survival rate in Stage II and III were 72% and 67.9%, respectively. The median months of overall survival in Stage II, III and IV were 60.4, 56.3 and 18.7, respectively. Conclusions: A treatment strategy with laparoscopic resection followed by decompression with a drainage tube was performed feasibly and safely. At this time, the effects of a stent on oncological prognosis is unclear, and this strategy could be an effective treatment for obstructive colorectal cancer.

[A Case of Rectal Cancer with Multiple Endocrine Neoplasia Type 2]

A 63-year-old man with multiple endocrine neoplasia type 2(MEN2)was admitted to the hospital because of positive fecal occult blood tests. Colonoscopy revealed a 50mm type 2 tumor at the rectum, which was diagnosed as an adenocarcinoma based on histology. Since there was no apparent distant metastasis, laparoscopy-assisted low anterior resection with regional lymph node dissection was performed. The final diagnosis was pT3, pN0, pM0, pStage II . Almost all patients with MEN2 have RET mutations, and they are resistant to EGFR inhibitors. Those who have thyroid cancer with RET mutations are often given a RET kinase inhibitor. In this case, if the patient develops recurrent rectal cancer, it warrants checking for RET mutations and using a multi-kinase inhibitor.

[A Case of Ascending Colon Cancer with Lynch Syndrome Who Underwent XELOX Adjuvant Chemotherapy]

Lynch syndrome is an inherited syndrome with the development of the colorectal and various other cancers. Lynch syndrome is caused by mutations in the mismatch repair genes. A 33 year-old male underwent XELOX adjuvant chemotherapy for ascending colon cancer with Lynch syndrome. Although efficacy of 5-FU is not demonstrated in Lynch syndrome, MOSAIC trial had suggested a benefit from FOLFOX compared with 5-FU in patients who have colorectal cancer with Lynch syndrome. Oxaliplatin-based adjuvant chemotherapy can be a therapeutic option for colorectal cancer in lynch syndrome patients.

[The Treatment Outcomes of FOLFIRINOX for Unresectable and Recurrent Pancreatic Cancer]

FOLFIRINOX is now considered to be a highly effective regimen for patients with metastatic pancreatic cancer. We administered FOLFIRINOX therapy in 18 patients between October 2014 and April 2017 as follows: 2-hour infusion of L-OHP at a dose of 85mg/m2, 2-hour infusion of LV at a dose of 200 mg/m2, infusion of CPT-11 for over 90 minutes at a dose of 150 mg/m2, followed by continuous infusion of 5-FU over 46 hours at a dose of 2,400mg/m2. The median age of the patients was 66.5 years. There were 15 patients with performance status(PS)0, and 3 with PS 1. Two patients were Stage III and 16 patients were Stage IV . More than half of the patients had over Grade 3 hematological or non-hematological toxicities. The most common adverse event was neutropenia. Two patients had Grade 5 adverse events: severe cholangitis occurred in the patient with a biliary stent and overwhelmingpost -splenectomy infection occurred in the patient who underwent distal pancreatectomy. The response rate was 11.1%, and the disease control rate was 77.8%. FOLFIRINOX was effective in the patients with unresectable and recurrent pancreatic cancer. However, it is necessary to examine the eligibility of the patients.

[A Case of Resection of Obstructive Colon Cancer Associated with Aspiration Pneumonia, Under Combined Epidural-Spinal Anesthesia]

An 89-year-old woman was admitted to our hospital with vomiting, abdominal distension, and anorexia.A CT scan revealed an enhanced thickening lesion on the wall of the ascending colon, and intestinal expansion from the small intestine to the caecum.On colon fibroscopy, a round tumor was observed adjacent to the oral side of the hepatic flexure even though the end of the microscope could not progress toward the deeper regions.As the obstructive colon cancer was complicated by the presence of aspiration pneumonia, surgery could not be performed under general anesthesia.We initiated curative therapy for aspiration pneumonia right at the onset.Subsequently, due to lack of improvement in the patient's general condition, we conducted a right hemicolectomy under combined epidural-spinal anesthesia.

[Laparoscopic Pancreatectomy for Pancreatic Neuroendocrine Tumor - A Single Institution Experience]

BACKGROUND

Pancreatic neuroendocrine tumor(P-NET)is relatively rare and often has less aggressive biological behavior. P-NET was re-designated by the WHO in 2010 and 2017. Laparoscopic surgery is minimally invasive but has technical difficulties such as limitation of movement and laparoscopic view. The purpose of this study is to evaluate the efficacy of laparoscopic pancreatectomy(LPT)for P-NET.

METHODS

Between January 2012 and June 2017, 6 patients underwent LPT for P-NET at Kansai Rosai Hospital. Five patients who received open pancreatectomy(OPT)for P-NET and 41 patients who received laparoscopic distal pancreatectomy(LDP)for cystic tumor(CyT)or invasive ductal carcinoma(IDC)were included for comparison.

RESULTS

All patients who underwent LPT for P-NET were NET G1 in WHO Classification 2017 and Stage I in UICC TNM 2016. No significant differences were noted between LPT and OPT groups with respect to patient age or gender. Operation time was 421.5 versus 423.5 minutes(ns), blood loss was 121.7 versus 1,918.3mL(ns), hospital stay was 20.5 versus 58.0 days(ns)for LPT and OPT respectively. In LDP, there were no significant differences between PNEN, CyT, and IDC groups with respect to patient age, gender, operation time, blood loss and hospital stay. All patients who underwent LPT for P-NET alive without recurrence. The average observation period was 58.4 months.

CONCLUSIONS

Laparoscopic pancreatectomy is safe and effective approach to the management of pancreatic neuroendocrine neoplasm.

[A Case of Neuroendocrine Tumor of the Ileum Manifesting as Fecal Occult Blood]

A 42-year-old woman was admitted to our hospital because of a positive fecal occult blood test. Colonoscopy examination revealed an elevated lesion measuring 25mm in diameter at the terminal ileum. A histological diagnosis of neuroendocrine tumor(NET)was made based on biopsy specimens taken from the lesion. Since no apparent distant metastasis other than the ileocolic lymph nodes was noted, laparoscopy-assisted ileocecal resection with regional lymph node dissection was performed. In the resected material, NET(G2)limited to the subserosa layer was present. The NET tested positive for synaptophysin, chromogranin A, and CD56. Metastases in the paraileal lymph nodes was detected. NET metastasis to the ileum is frequent, even if the tumor is small in diameter; therefore, it is necessary to resect the tumor entirely and to dissect the regional lymph nodes.

[Multidisciplinary Treatment for High-Risk GIST of the Stomach]

A 59-year-old man underwent total gastrectomy(with D2 dissection)and cholecystectomy for gastric cancer and a submucosal tumor of the stomach. The specimen was immunohistochemically positive for c-kit, the Ki-67 label index was 10%, and the mitotic count was 20/HPF. Finally, the patient was diagnosed with high-risk gastrointestinal stromal cancer with normal type gastric cancer. After discharge from hospital, we started administration of TS-1 as adjuvant therapy for the gastric cancer. As multiple recurrences of the GIST in the abdomen developed, the patient underwent 3 radical local resections. Mutational analysis revealed a PDGFRA mutation in exon 18, which causes resistance to both imatinib and sunitinib. As he was refractory to imatinib, the patient received regorafenib. After a while, it caused liver failure, which required 7 rounds of plasmapheresis. The patient died from multiple organ failure resulting from multiple recurrences 4 years after the first surgery.

[A Case of Schwannoma Originating from the Sciatic Nerve]

A 75-year-old man was admitted with abdominal pain and taken to our hospital. CT and MRI showed a tumor measuring 60mm in diameter in the pelvic cavity. Based on the imaging findings, we suspected a schwannoma and decided to perform surgery. As the tumor was found to be benign in intraoperative frozen section diagnosis, the tumor was enucleated. Histopathological findings showed no nuclear atypia, and the patient was diagnosed with a schwannoma. He complained of paresthesia in his right leg after surgery, and underwent walking training. Six months after surgery, no recurrence was found.

[A Case of Gastric Cancer Associated with Membranous Glomerulonephritis]

An 81-year-old woman was admitted for leg edema. She was found to have membranous glomerulonephritis with advanced gastric cancer after renal biopsy and endoscopic examination. Serum albumin was 1.4 g/dL and total protein was 4 g/dL on admission. After albumin was administered, distal gastrectomy was performed. Albumin administration continued post-operatively. The post-operative course was unremarkable and she was discharged on post-operative day 19. Six months after the operation, serum albumin gradually increased and uric protein volume decreased. Possible remission of membranous glomerulonephritis with gastric cancer can be expected after gastrectomy but careful perioperative management is required.

Spinal cord ring enhancement in patients with neuromyelitis optica

OBJECTIVES

Clinical and pathological significance of gadolinium (Gd)-enhancing pattern on magnetic resonance imaging (MRI), including ring enhancement (RE), is well documented in multiple sclerosis but not in neuromyelitis optica (NMO), especially in the spinal cord. The purpose of this study is to examine the prevalence of spinal cord RE in NMO and to determine the association between clinical characteristics and spinal cord RE.

MATERIALS AND METHODS

We retrospectively examined Gd-enhanced spinal cord MRI scans, during the acute phase, in patients with anti-aquaporin 4-positive NMO, including NMO spectrum disorder. We then analysed their clinical features and MRI imaging characteristics of spinal cord lesions.

RESULTS

Of the 30 patients with NMO, we enrolled 12 patients with 16 Gd-enhanced spinal cord MRI scans in this study. Five scans revealed RE (31.2%). Male ratio, as well as myelin basic protein (MBP) levels, in the cerebrospinal fluid (CSF) of patients with RE was significantly higher than those of patients without RE (P = 0.018, P = 0.026, respectively).

CONCLUSIONS

Spinal cord RE is common in patients with NMO. Higher MBP levels in the CSF of patients with RE can be associated with a higher degree of myelin damage.

Detection and avoiding ventricular suction of ventricular assist devices

Continuous flow blood pumps, such as axial flow and centrifugal pumps, have been gaining interest as circulatory devices for total artificial hearts (TAHs) and a biventricular assist device (BVAD) because of their smaller size and simpler structure compared to pulsatile pumps. However, continuous flow pumps are more prone to suction of the left ventricle than pulsatile pumps are. Sudden increases in flow rate to meet changes in physiological demand, especially in the left pump, often cause ventricle suction. In this study, a control algorithm to prevent suction from occurring in the left ventricle by controlling the rotational speed of the right pump, instead of reducing the cardiac output of the left pump, was developed and investigated. The method was tested in acute animal experiments with calves. The results indicate that this proposed method is capable of preventing suction and could simultaneously maintain circulatory control. A key advantage of this control system is that flow rates can be maximized while avoiding ventricle suction conditions particularly when the circulatory system is unstable such as in a the first few days after operation.

Recurrence risk factors in patients with the Vogt-Koyanagi-Harada syndrome in Japan

The Vogt-Koyanagi-Harada (VKH) syndrome is a form of recurrent uveitis with often a poor long-term visual acuity. The risk factors for recurrence of the VKH syndrome were investigated statistically by using a multiple logistic regression model. The clinical data of 87 patients were used for the statistical analysis. Among them, 58 patients (66.8%) had no recurrences, while 29 patients (33.3%) had recurrences. By multiple logistic regression analysis, dysacousia (p<0.01), cutaneous manifestations (p<0. 05), prodromal symptoms (p<0. 05), onset to treatment interval (days) (p<0. 05) and retinal detachment (p<0. 01) were significantly and independently associated with the recurrence. The Relapse Score was constructed by using a logistic model as follows: Relapse Score=+1. 459X (Dysacousia) + 1. 458x (Cutaneous manifestations) +0. 032x (Onset to treatment interval) -1. 637x (Prodromal symptoms) -1. 773x (Retinal detachment)+1. 247. It is supposed that the Relapse Score might be helpful for predicting the clinical course and modifying the dose or duration of systemic steroid therapy of the patients with the VKH syndrome.

Evaluation of the Wear of the Pivot Bearing in the Gyro C1E3 Pump

To estimate the lifetime of the pivot bearing system of the sealless centrifugal Gyro C1E3 pump, pivot bearing wear phenomena of the C1E3 were studied. The pivot bearing system consisted of a male and female pivot made of ceramics and ultrahigh molecular weight polyethylene (UHMWPE), respectively. First, many pumping tests were performed with the C1E3 under various pumping conditions, and the effects of impeller position and fluid on wear were analyzed. Through these preliminary tests, it was found that the wear progress of the pivot bearing consisted of initial wear and stationary wear. Most of this initial wear is caused by the plastic deformation of the polyethylene female pivot. It also was observed that bovine blood was almost comparable to water in its effect on the stationary wear rate at the same rotational speed. Based on these results, a long-term pumping test was performed with the C1E3, and initial and stationary wear rates were determined. At the same time, the maximal loosening distance (LDmax) (permissible total wear) of the C1E3 was determined experimentally from hemolytic and hydraulic performance perspectives. By using experimentally determined parameters the lifetime of the pivot bearing system of the C1E3 pump was estimated for various pumping conditions. The lifetime of the pivot bearing system of the C1E3 was typically 10 years for right ventricular assist, 8 years for left ventricular assist, and 5 years for cardiopulmonary bypass.

Comparison of acute non-haemolytic transfusion reactions in female and male patients receiving female or male blood components

To study the relationship between antibodies detected in patients’ and/or donors’ sera and the clinical features of acute non-haemolytic transfusion reactions (ANHTRs), and to determine any gender-related difference. ANHTRs range from urticaria to transfusion-related acute lung injury (TRALI). Antibodies to human leukocyte antigen (HLA), granulocytes, platelets, and/or plasma proteins are implicated in some of the ANHTRs. A higher antibody positivity is expected for females than for males. A comparative study of ANHTRs for antibody positivity and their clinical features between females and males for both patients and donors is helpful for characterizing ANHTRs including TRALI more clearly, but such studies are few and outdated. Two hundred and twenty-three ANHTR cases reported by 45 hospitals between October 2000 and July 2005 were analysed. The patients and 196 donors of suspect blood products were screened for antibodies to HLA Class I, HLA Class II, granulocytes, and platelets. The patients were also screened for anti-plasma protein antibodies. The types and severity of ANHTR did not differ significantly between female and male patients. The frequency of the anti-HLA antibodies, but not that of the non-HLA antibodies, was significantly higher in females. Non-HLA antibodies were significantly associated with severe reactions in females. All the TRALI cases had predisposing risk factors for acute lung injury, and 60% of the cases showed anti-leucocyte antibodies. Although the anti-HLA antibodies were detected more frequently in females than males, no significant association of ANHTRs including TRALI with gender, not only for patients, but also for donors, could be shown in this study.

Retrospective study of post-anesthetic mild liver disorder associated with inhalation anesthetics, halothane and enflurane

The incidence of post-anesthetic mild liver disorder (PAMLD) was compared between 928 patients administered halothane and 1766 patients administered enflurane. They were selected from 19 504 surgical patients administered general anesthesia at Kyushu University Hospital over the past 6 years and 4 months. They had had normal liver function before operation and had no history of blood transfusion. Alanine aminotransferase (ALT) levels exceeding 70 IU. l(-1) within 180 days after operation were found in 226 patients in the halothane group (24.4%), and in 250 patients in the enflurane group (14.2%) ( P < 0.01). Both maximum ALT levels and duration of ALT elevation were higher and longer in the halothane group ( P < 0.01). These results suggest that, not only in the development of fulminant hepatitis but also in PAMLD, enflurane is less hepatotoxic than halothane.

Comparison of diagnostic methods for diabetes mellitus based on prevalence of retinopathy in a Japanese population: the Hisayama Study

AIMS/HYPOTHESIS

The aims of this study were to compare the ability of tests measuring fasting plasma glucose, 2-h plasma glucose and HbA1c levels in predicting specific diabetic retinopathy, and to determine the cut-off level of each measurement for diagnosing diabetes in a Japanese population.

METHODS

In a total of 1637 subjects, fasting plasma glucose, 2-h plasma glucose and HbA1c levels were measured in a 75-g oral glucose tolerance test, and diabetic retinopathy was assessed by ophthalmic examination. We calculated receiver operating characteristic (ROC) curves as well as the prevalence of diabetic retinopathy by deciles of the distribution of these glycaemic measurements.

RESULTS

Of the subjects, 37 (2.3%) had diabetic retinopathy. The prevalence of retinopathy dramatically increased in the tenth decile of each variable. Analysis with ROC curves showed that the optimal cut-off levels for diagnosis of diabetes were 6.4 mmol/l for fasting plasma glucose, 11.1 mmol/l for 2-h plasma glucose, and 5.7% for HbA1c. The sensitivities for the cut-off point of the three measurements were identical (86.5%), and the specificities were similar (fasting plasma glucose 87.3%; 2-h plasma glucose 89.6%; HbA1c 90.1%). The area under the ROC curve for 2-h plasma glucose (96.1%) was slightly but not significantly larger than that for fasting plasma glucose (90.0%) and that for HbA1c (94.5%).

CONCLUSIONS/INTERPRETATION

. Our findings suggest that measuring fasting plasma glucose or HbA1c is just as useful as measuring 2-h plasma glucose for the diagnosis of diabetes, and that the cut-off point for diagnostic fasting plasma glucose level is lower than that of the current diagnostic criteria.

Chemical peeling with salicylic acid in polyethylene glycol vehicle suppresses skin tumour development in hairless mice

BACKGROUND

Chemical peeling with salicylic acid in polyethylene glycol (PEG) vehicle is used clinically to improve the cosmetic appearance of skin that has been damaged by exposure to the sun. It is well known that cancers of the skin such as basal cell carcinoma and squamous cell carcinoma may be induced by the sun. However, the carcinogenic potential of chemical peeling agents has not been studied.

OBJECTIVES

To evaluate the effects of chemical peeling with 30% salicylic acid in PEG on skin tumour formation in treated vs. control mice.

METHODS

To serve as a model of sun-damaged skin, hairless SKH/hr1 mice were irradiated with ultraviolet (UV) B for 14 weeks, with or without treatment every 2 weeks with 30% salicylic acid in PEG for a total of 18 weeks.

RESULTS

Not only was the total number of tumours greatly reduced in the treated vs. the control mice, but skin tumour development was also slower in the treated vs. the control mice. At the final treatment, the fractions of T and B lymphocytes and natural killer cells from spleens of both groups of mice were comparable, and interferon-gamma production did not differ.

CONCLUSIONS

Our findings suggest that chemical peeling with salicylic acid in PEG may help to prevent as well as to reduce the number of UVB-induced skin tumours.