CA19-9 in Combination with Methylated HOXA1 and SST Is Useful to Diagnose Stage I Pancreatic Cancer.

INTRODUCTION: We previously developed a novel methylation assay, the combined restriction digital PCR (CORD) assay, consisting of treatment of DNA with methylation-sensitive restriction enzymes and droplet digital PCR. METHODS: In this study, we assessed the diagnostic performance of serum methylated Homeobox A1 (mHOXA1) and methylated somatostatin (mSST) using the CORD assay in combination with CA19-9 for pancreatic cancer using serum samples from 82 healthy individuals, 13 patients with benign pancreatic disease, 3 patients with branched-duct intraductal papillary mucinous neoplasm, and 91 patients with pancreatic cancer. RESULTS: For the single marker tests, sensitivity for all stages of pancreatic cancer, stage I cancer, and specificity were, respectively, 71.4%, 50.0%, and 94.9% for CA19-9; 51.6%, 68.8%, and 90.8% for mHOXA1; and 50.1%, 68.8%, and 94.9% for mSST. Those for the combined marker tests were, respectively, 86.8%, 81.3%, and 85.7% for combined mHOXA1 and CA19-9; 86.8%, 87.5%, and 89.8% for combined mSST and CA19-9; and 89.0%, 87.5%, and 85.7% for all three markers combined. CONCLUSION: The combination of mHOXA1 and mSST with CA19-9 appears to be useful to detect pancreatic cancer even at an early stage.

Combination of CA19-9 and Blood Free-Circulating Methylated RUNX3 May Be Useful to Diagnose Stage I Pancreatic Cancer.

BACKGROUND: Although serum carbohydrate antigen 19-9 (CA19-9) is widely used as a useful biomarker of pancreatic cancer for monitoring the response to therapy, it is not recommended for screening of early pancreatic cancer because of its limited sensitivity for small tumors. Thus, it is critical to discover novel serum biomarkers to complement CA19-9 in order to improve sensitivity. Although methylated runt-related transcription factor 3 (RUNX3) is a biomarker of pancreatic cancer, its detection by conventional bisulfite-based methylation assays from a small serum sample amount is very difficult. Therefore, we developed a new methylation assay, the combined restriction digital PCR (CORD) assay, that enables counting of even one copy of a methylated gene in a small DNA sample amount without DNA bisulfite treatment. OBJECTIVES: We evaluated the sensitivity and specificity of serum DNA testing of methylated RUNX3 by the CORD assay in combination with and without CA19-9 for the detection of pancreatic cancer in 55 patients with pancreatic cancer, 12 patients with benign pancreatic disease, and 80 healthy individuals. RESULTS: The CORD assay of methylated RUNX3 had a sensitivity of 50.9% (28/55) and specificity of 93.5% (86/92). Combination of the CORD assay of methylated RUNX3 and CA19-9 resulted in a sensitivity of 85.5% (47/55) and specificity of 93.5% (86/92) for all stages of pancreatic cancer and a sensitivity of 77.8% (7/9) for stage I pancreatic cancer. CONCLUSIONS: ombination of the CORD assay and CA19-9 may provide an alternative screening strategy for detecting early-stage pancreatic cancer.

A case of multiple glucagonomas with no clinical manifestations of excess glucagon despite hyperglucagonemia.

Herein we report the case of a patient with multiple glucagonomas that have been precisely described with endoscopic ultrasound. A 36-year-old woman was referred to our hospital for computed tomography investigation of multiple pancreatic masses. Physical examination was unremarkable; on contrast-enhanced computed tomography, mass lesions were evident in the head, body, and tail of the pancreas. The mass in the pancreatic head was poorly demarcated and exhibited a faint contrast effect, the one in the pancreatic body was a cystic lesion, and the one in the pancreatic tail was hypervascular. Blood investigations showed that serum glucagon was abnormally high at 7670 pg/ml; glucose tolerance was not impaired. There was no family history that suggested multiple endocrine neoplasia type 1 or von Hippel-Lindau disease. Endoscopic ultrasound revealed that there were additional masses, which were scattered isoechoic to hyperechoic lesions a few millimeters in size. Ultrasound-guided fine needle biopsy of the lesion in the pancreatic tail resulted in a diagnosis of a neuroendocrine tumor. Based on these pathologic findings, we performed a total pancreatectomy. A large number of nodules with tumor cells were evident in all cut surfaces of the surgical specimen. Immunostaining was positive for chromogranin A and glucagon, and glucagonoma was therefore diagnosed. It is conceivable that attenuated glucagon action could have contributed to the development of the multiple glucagonomas.

Comparison of Duodenal Stenting and Gastrojejunostomy for Duodenal Obstruction with Biliary Obstruction.

BACKGROUND: The best palliation for double obstruction (duodenal obstruction with biliary obstruction) remains unclear. We aimed to compare outcomes of duodenal stenting (DuS) with gastrojejunostomy (GJ) and identify factors associated with survival time and time to recurrent biliary obstruction (TRBO). METHODS: Patients who underwent DuS or GJ combined with biliary stenting for double obstruction due to unresectable malignancy were retrospectively enrolled. RESULTS: In total, 111 patients were included; 84 underwent DuS, and 27 underwent GJ. The weighted survival time of the DuS group was significantly shorter than that of the GJ group (86 days vs 134 days, P < 0.01). Although the weighted TRBO was not significantly different between the two groups, when limited to patients with distal duodenal obstruction, the weighted TRBO was significantly longer in the DuS group than in the GJ group (207 days vs. 32 days, P < 0.01). GJ for distal duodenal obstruction was identified as the factor with the highest hazard ratio and was associated with a shorter TRBO (hazard ratio 8.5, P < 0.01). CONCLUSIONS: Regarding survival time, GJ should be considered the primary treatment for patients with double obstruction. However, for patients with distal duodenal obstruction, DuS should be considered because GJ may be a risk factor for a shorter TRBO.

Heat Shock Protein 27 Expression in EUS-FNA Samples Can Predict Gemcitabine Sensitivity in Pancreatic Cancer.

BACKGROUND/AIM: Gemcitabine (GEM) sensitivity can help select the appropriate treatment for pancreatic cancer. We examined the association between HSP27 expression and GEM sensitivity. MATERIALS AND METHODS: A total of 19 patients with unresectable pancreatic cancer who underwent endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA) were enrolled and treated with GEM alone. We measured the expression of heat shock protein 27 (HSP27) and phosphorylated HSP27(p-HSP27) in EUS-FNA samples and evaluated the effects of GEM treatment. RESULTS: The rate of GEM resistance was significantly higher in patients who showed overexpression of p-HSP27 (p<0.05). When we set the cut-off p-HSP27 (Ser82) detection rate at 51.6%, the group with a detection rate of >51.6% showed a significantly lower survival rate, and GEM was administered for a shorter period of time (p<0.05). CONCLUSION: It was suggested that the HSP27 expression in EUS-FNA samples was useful for predicting GEM sensitivity.

Association between isolation sites of methicillin-resistant Staphylococcus aureus (MRSA) in patients with MRSA-positive body sites and MRSA contamination in their surrounding environmental surfaces.

In 106 inpatients with methicillin-resistant Staphylococcus aureus (MRSA)-positive body sites, MRSA contamination on their surrounding environmental surfaces and the palm of their dominant hand were detected and quantified. The association between MRSA-positive sites (palm of dominant hand, sputum, nasal discharge, pharyngeal mucosa, open pus, closed pus, urine, feces, and others) in patients and MRSA contamination in their surrounding environmental surfaces was evaluated by quantification theory II of multivariate analysis. The surrounding environmental surfaces were contaminated with MRSA in 54 (50.9%) of the 106 patients. The contamination of MRSA was 380.2 +/- 2,198.0 colony forming units (cfu)/100 cm(2) in 41 (40.2%) of 102 bed linen samples, 15.2 +/- 69.5 cfu/100 cm(2) in 19 (22.4%) of 85 overbed table samples, 12.8 +/- 56.5 cfu/about 100 cm(2) in 18 (20.9%) of 86 bed side rail samples, and 0.2 +/- 1.3 cfu/entire handle surface in 2 (2.7%) of 74 samples of room door handles on the inner side of the patients' room doors. In the palm, 6,743.3 +/- 65,446.5 cfu/palm MRSA was detected in 29 (29.6%) of 98 patients. MRSA in patients' palms had the most marked influence on MRSA contamination of their surrounding environmental surfaces. When MRSA is detected in patients' palms the possibility of MRSA contamination of their surrounding environmental surfaces is high.

Side-by-side placement of bilateral endoscopic metal stents for the treatment of postoperative biliary stricture.

Postoperative biliary strictures are usually complications of cholecystectomy. Endoscopic plastic stent prosthesis is generally undertaken for treating benign biliary strictures. Recently, fully covered metal stents have been shown to be effective for treating benign distal biliary strictures. We present the case of a 53-year-old woman with liver injury in which imaging studies showed a common hepatic duct stricture. Endoscopic retrograde cholangiopancreatography also confirmed the presence of a common hepatic duct stricture. Temporally fully covered metal stents with dilated diameters of 6 mm were placed in a side-by-side fashion in the left and right hepatic ducts, respectively. We removed the stents 2 months after their placement. Subsequent cholangiography revealed an improvement in the biliary strictures. Although we were apprehensive about the fully covered metal stents obstructing the biliary side branches, we noted that careful placement of the bilateral metal stents did not cause any complications. Side-by-side deployment of bilateral endoscopic fully covered metal stents can be one of the safe and effective therapies for postoperative biliary stricture.

Efficacy of contrast-enhanced harmonic endoscopic ultrasonography in the diagnosis of pancreatic ductal carcinoma.

BACKGROUND/AIMS: Distinguishing pancreatic ductal carcinoma (DC) from other pancreatic masses remains challenging. This study aims at evaluating the efficacy of contrast-enhanced harmonic endoscopic ultrasonography (CEH-EUS) in the diagnosis of DC. PATIENTS AND METHODS: Forty-nine patients with solid pancreatic mass lesions underwent CEH-EUS. EUS (B-mode) was used to evaluate the inner echoes, distributions, and borders of the masses. The vascular patterns of the masses were evaluated with CEH-EUS at 30-50 s (early phase) and 70-90 s (late phase) after the administration of Sonazoid®. RESULTS: The final diagnoses included DCs (37), mass-forming pancreatitis (6), endocrine neoplasms (3), a solid pseudopapillary neoplasm (1), a metastatic carcinoma (1), and an acinar cell carcinoma (1). The sensitivity, specificity, and accuracy of the diagnoses of DC in hypoechoic masses using EUS (B-mode) were 89.2%, 16.7%, and 71.4%, respectively. The sensitivity, specificity, and accuracy for the diagnosis of DC in hypovascular masses using CEH-EUS were 73.0%, 91.7%, and 77.6% in the early phase and 83.8%, 91.7%, and 85.7% in the late phase, respectively. CONCLUSIONS: CEH-EUS for the diagnosis of DC is superior to EUS. CEH-EUS in the late phase was particularly efficacious in the diagnosis of DC.

Differential diagnosis of benign and malignant branch duct intraductal papillary mucinous neoplasm using contrast-enhanced endoscopic ultrasonography.

AIM: To elucidate the role of contrast-enhanced endoscopic ultrasonography (CE-EUS) in the diagnosis of branch duct intraductal papillary mucinous neoplasm (BD-IPMN). METHODS: A total of 50 patients diagnosed with BD-IPMN by computed tomography (CT) and endoscopic ultrasonography (EUS) at our institute were included in this study. CE-EUS was performed when mural lesions were detected by EUS. The diagnostic accuracy for identifying mural nodules (MNs) was evaluated by CT, EUS, and EUS combined with CE-EUS. In the patients who underwent resection, the accuracy of measuring MN height with each imaging modality was compared. The cut-off values to diagnose malignant BD-IPMNs based on MN height for each imaging modality were determined using receiver operating characteristic curve analysis. RESULTS: Fifteen patients were diagnosed with BD-IPMN with MNs and underwent resection. The remaining 35 patients were diagnosed with BD-IPMN without MNs and underwent follow-up monitoring. The pathological findings revealed 14 cases with MNs and one case without. The accuracy for diagnosing MNs was 92% using CT and 72% using EUS; the diagnostic accuracy increased to 98% when EUS and CE-EUS were combined. The accuracy for measuring MN height significantly improved when using CE-EUS compared with using CT or EUS (median measurement error value, CT: 3.3 mm vs CE-EUS: 0.6 mm, P < 0.05; EUS: 2.1 mm vs CE-EUS: 0.6 mm, P < 0.01). A cut-off value of 8.8 mm for MN height as measured by CE-EUS improved the accuracy of diagnosing malignant BD-IPMN to 93%. CONCLUSION: Using CE-EUS to measure MN height provides a highly accurate method for differentiating benign from malignant BD-IPMN.

Active hexose-correlated compound down-regulates HSP27 of pancreatic cancer cells, and helps the cytotoxic effect of gemcitabine.

BACKGROUND/AIM: Active hexose-correlated compound (AHCC), an extract of basidiomycete mushroom, is used as health food to enhance the therapeutic effects and reduce the adverse effects of chemotherapy. Our previous proteomic analysis revealed that up-regulation of heat-shock protein 27 (HSP27) was responsible for gemcitabine resistance of pancreatic cancer cells. The aim of the present study was to investigate the effect of AHCC on the expression of HSP27 and the effect of combinatorial treatment of AHCC and gemcitabine on the gemcitabine-resistant pancreatic cancer cell line KLM1-R. MATERIALS AND METHODS: KLM1-R cells were treated with AHCC, and the expression of HSP27 as well as the cytotoxic effects of combinatorial treatment of AHCC and gemcitabine were investigated with western blotting and MTS assay, respectively. RESULTS: AHCC down-regulated HSP27 and exhibited a cytotoxic effect on KLM1-R cells. Furthermore, the cytotoxic effect of the combinatorial treatment of AHCC and gemcitabine was synergistic. CONCLUSION: This study supports the potential therapeutic benefits of combinatorial treatment of AHCC and gemcitabine for patients with pancreatic cancer.

Active hexose-correlated compound down-regulates sex-determining region Y-box 2 of pancreatic cancer cells.

BACKGROUND/AIM: Active hexose-correlated compound (AHCC) is an extract of basidiomycete mushroom. It has been used as health food due to its efficacy of enhancing antitumor effects and reducing adverse effects of chemotherapy. Our previous research showed that AHCC down-regulated heat-shock protein (HSP)-27 and exhibited cytotoxic effects against gemcitabine-resistant pancreatic cancer cells. Sex-determining region Y-box 2 (SOX2) is reported to be up-regulated in other kinds of cancer cells and involved in carcinogenesis and malignancy. The aim of this study was to investigate the effects of AHCC on protein expression of SOX2 in the gemcitabine-resistant pancreatic cancer cell line KLM1-R. MATERIALS AND METHODS: AHCC was applied to KLM1-R cells and expression of SOX2 was analyzed by western blotting. RESULTS: AHCC down-regulated SOX2 in KLM1-R cells. Nanog and Oct4, co-workers of SOX2 in maintaining pluripotency, did not exhibit any significant change in protein expression. CONCLUSION: We showed the potential of AHCC to be a candidate for combinatorial therapy in anticancer drug regimens. This result suggests that the target of AHCC in expressing therapeutic efficacy was not the pluripotent cells such as cancer stem cells (CSCs) but SOX2-specific.

Up-regulation of DDX39 in human pancreatic cancer cells with acquired gemcitabine resistance compared to gemcitabine-sensitive parental cells.

Intrinsic or acquired resistance of pancreatic cancer to gemcitabine (2'-deoxy-2'-difluorodeoxycytidine) is an important factor in the failure of gemcitabine treatment. Proteomic analysis of gemcitabine-sensitive KLM1 pancreatic cancer cells and -resistant KLM1-R cells identified heat-shock protein-27(HSP27) as a biomarker protein which is involved in gemcitabine resistance. However, a knock-down experiment showed that HSP27 was not the only protein implicated with gemcitabine-resistance. Finding further candidate proteins is necessary for achieving effective gemcitabine therapy for patients with pancreatic cancer. DDX39 is an Asp-Glu-Ala-Asp (DEAD)-box RNA helicase reported to be overexpressed in tumor cells, such as lung squamous cell cancer, gastrointestinal stromal tumor, urinary bladder cancer and malignant pleural mesothelioma. In urinary bladder cancer cells, overexpression of this protein is intimately bound with tumorigenesis and poor prognosis. In the present study, the expression of DDX39 in gemcitabine-sensitive KLM1 and -resistant KLM1-R cells was compared. It was found that DDX39 was significantly up-regulated in gemcitabine-resistant KLM1-R cells compared to sensitive KLM1 cells. The ratio of expression of DDX39 to that of actin was significantly up-regulated in KLM1-R cells compared to KLM1 cells (p=0.0072 by Student's t-test). These results suggest that DDX39 is a possible candidate biomarker for predicting the response of patients with pancreatic cancer to treatment with gemcitabine.

Human pancreatic cancer cells with acquired gemcitabine resistance exhibit significant up-regulation of peroxiredoxin-2 compared to sensitive parental cells.

Gemcitabine (2'-deoxy-2'-difluorodeoxycytidine) is the only clinically effective drug for pancreatic cancer. However, high levels of inherent and acquired tumor resistance to gemcitabine lead to difficulty of chemotherapy for pancreatic cancer. We have reported on a proteomic study of gemcitabine-sensitive KLM1 and -resistant KLM1-R pancreatic cancer cells, and identified some proteins which were shown to be up-regulated in KLM1-R compared to KLM1 cells. In those proteomic studies, peroxiredoxin-2 was listed as an up-regulated protein in KLM1-R cells. Peroxiredoxin-2 is a member of a family of peroxiredoxins providing a protective role for redox damage. In this study, the expression of peroxiredoxin-2 in KLM1 and KLM1-R cells was compared. It was found that peroxiredoxin-2 was significantly up-regulated in KLM1-R cells compared to KLM1 cells (p<0.001). However, peroxiredoxin-1 expression was significantly down-regulated in KLM1-R cells (p<0.001). These results suggest that peroxiredoxin-2 is a possible candidate biomarker for predicting the response of patients with pancreatic cancer to treatment with gemcitabine.

A case of EMRC for basaloid squamous carcinoma of the cervical esophagus.

Basaloid squamous carcinoma (BSC) of the esophagus is a rare esophageal tumor. A 79-year-old man with a history of proximal gastrectomy for gastric adenocarcinoma in 2000 was followed-up by esophagogastroduodenoscopy (EGD) annually. In June 2010, EGD revealed a new protruding lesion in the cervical esophagus. The small lesion was approximately 5 mm in size. A biopsy specimen showed poorly differentiated squamous cell carcinoma. We performed endoscopic mucosal resection using a cap-fitted endoscope (EMRC). The histological diagnosis of the endoscopically resected specimen was BSC and the invasion depth was limited to the muscularis mucosae. Horizontal and vertical margins were negative. We report the case of superficial BSC in the cervical esophagus successfully resected by EMRC.

Heat-shock protein 27 plays the key role in gemcitabine-resistance of pancreatic cancer cells.

Pancreatic cancer is one of the most fatal types of cancer in developed countries. Most patients have locally advanced or metastatic cancerous lesions when they are diagnosed, due to the progressive, invasive and metastatic capacity of this disease to liver, lymph nodes and distant organs during early stages. Although the only curative therapy is complete surgical resection, the disease has usually already progressed by the time of diagnosis, and the majority of patients have metastatic disease. Therefore, palliative chemotherapy remains the only therapy for patients with progressive disease. Gemcitabine has been used for pancreatic cancer as the most effective anticancer drug. However, there are many cases resistant to gemcitabine. Thus, a better understanding of the molecular mechanisms of resistance to gemcitabine is essential to allow it to be used more effectively. Our previous proteomic studies demonstrated that the expression of heat-shock protein 27 (HSP27) was increased in gemcitabine-resistant pancreatic cancer cells and this might play a role in determining the sensitivity of pancreatic cancer to gemcitabine. Increased HSP27 expression in tumor specimens was related to resistance to gemcitabine and a shorter survival period in patients with pancreatic cancer. Furthermore, it has been shown that treatment strategies combining the HSP inhibitor KNK437 or interferon-γ (IFN-γ) with gemcitabine, were effective in gemcitabine-resistant pancreatic cancer cells in vitro. Furthermore, combined therapy of gemcitabine with IFN-γ of gemcitabine-resistant pancreatic cancer-bearing nude mice showed synergistic therapeutic effects on gemcitabine-resistant pancreatic cancer bearers. In this review, we summarize the current understanding of HSP27 and its role in gemcitabine resistance.

Utility of the Anterior Oblique-Viewing Endoscope and the Double-Balloon Enteroscope for Endoscopic Retrograde Cholangiopancreatography in Patients with Billroth II Gastrectomy.

Background/Purpose. The difficulties of endoscopic retrograde cholangiopancreatography in patients with Billroth II gastrectomy have been reported. We evaluated the usefulness of an anterior oblique-viewing endoscope and a double-balloon enteroscope for endoscopic retrograde cholangiopancreatography in such patients. Methods. From January 2003 to December 2011, 65 patients with Billroth II gastrectomy were enrolled in this study. An anterior oblique-viewing endoscope was used for all patients. From February 2007, a double-balloon enteroscope was used for the failed cases. The success rate of procedures was compared with those in 20 patients with Billroth II gastrectomy using forward-viewing endoscope or side-viewing endoscope from March 1996 to July 2002 as historical controls. Results. In all patients in whom the papilla was reached (60/65), selective cannulation was achieved. The success rate of selective cannulation and accomplishment of planned procedures in the anterior oblique-viewing endoscope group were both significantly higher than that in the control group (100% versus 70.1%, 100 versus 58.8%, resp.). A double-balloon enteroscope was used in 2 patients, and the papilla could be reached and the planned procedures completed. Conclusions. An anterior oblique-viewing endoscope and double-balloon enteroscope appear to be useful in performing endoscopic retrograde cholangiopancreatography in patients with Billroth II gastrectomy.