Role of tumour location and surgical extent on prognosis in T2 gallbladder cancer: an international multicentre study.

BACKGROUND: In gallbladder cancer, stage T2 is subdivided by tumour location into lesions on the peritoneal side (T2a) or hepatic side (T2b). For tumours on the peritoneal side (T2a), it has been suggested that liver resection may be omitted without compromising the prognosis. However, data to validate this argument are lacking. This study aimed to investigate the prognostic value of tumour location in T2 gallbladder cancer, and to clarify the adequate extent of surgical resection. METHODS: Clinical data from patients who underwent surgery for gallbladder cancer were collected from 14 hospitals in Korea, Japan, Chile and the USA. Survival and risk factor analyses were conducted. RESULTS: Data from 937 patients were available for evaluation. The overall 5-year disease-free survival rate was 70·6 per cent, 74·5 per cent for those with T2a and 65·5 per cent among those with T2b tumours (P = 0·028). Regarding liver resection, extended cholecystectomy was associated with a better 5-year disease-free survival rate than simple cholecystectomy (73·0 versus 61·5 per cent; P = 0·012). The 5-year disease-free survival rate was marginally better for extended than simple cholecystectomy in both T2a (76·5 versus 66·1 per cent; P = 0·094) and T2b (68·2 versus 56·2 per cent; P = 0·084) disease. Five-year disease-free survival rates were similar for extended cholecystectomies including liver wedge resection versus segment IVb/V segmentectomy (74·1 versus 71·5 per cent; P = 0·720). In multivariable analysis, independent risk factors for recurrence were presence of symptoms (hazard ratio (HR) 1·52; P = 0·002), R1 resection (HR 1·96; P = 0·004) and N1/N2 status (N1: HR 3·40, P < 0·001; N2: HR 9·56, P < 0·001). Among recurrences, 70·8 per cent were metastatic. CONCLUSION: Tumour location was not an independent prognostic factor in T2 gallbladder cancer. Extended cholecystectomy was marginally superior to simple cholecystectomy. A radical operation should include liver resection and adequate node dissection.

ANTECEDENTES: En el cáncer de vesícula biliar, la ubicación del tumor subdivide el estadio T2 en tumores con invasión del lado peritoneal y del lado del hígado (T2a y T2b). Para los tumores que invaden el lado peritoneal (T2a) se sugiere que se puede obviar la resección hepática sin que ello comprometa el pronóstico. Sin embargo, este argumento no ha sido validado. El estudio tuvo como objetivo investigar el valor pronóstico de la localización del tumor en el cáncer de vesícula biliar T2 y establecer la extensión adecuada de la resección quirúrgica. MÉTODOS: Se recogieron los datos clínicos de pacientes que se sometieron a cirugía por cáncer de vesícula biliar en 14 hospitales de Corea, Japón, Chile y Estados Unidos. Se realizaron análisis de la supervivencia y de los factores de riesgo. RESULTADOS: Se dispuso de datos de 937 pacientes para ser evaluados. La tasa de supervivencia global libre de enfermedad a los 5 años fue del 70,6%, y las de T2a y T2b del 74,5% y 65,5% (P = 0,028). Con respecto a la resección hepática, la colecistectomía extendida presentó una tasa mejor de supervivencia libre de enfermedad a los 5 años que la colecistectomía simple (73,0% versus 61,5%, P = 0,012). La tasa de supervivencia libre de enfermedad a los 5 años fue marginalmente mejor para la colecistectomía extendida que para la colecistectomía simple tanto en T2a (76,5% versus 66,1%, P = 0,094) como en T2b (68,2% versus 56,2%, P = 0,084). Las tasas de supervivencia libre de enfermedad a los 5 años no fueron diferentes entre la resección hepática en cuña y la segmentectomía S4b+S5 (74,1% versus 71,5%, P = 0,720). En el análisis multivariable, los factores de riesgo independientes para la recidiva fueron la presencia de síntomas (cociente de riesgos instantáneos, hazard ratio, HR 1,52, P = 0,002), la resección R1 (HR 1,96, P = 0,004) y el estadio N1/N2 (N1 HR 3,40, P < 0,001; N2 HR 9,56, P < 0,001). El 70,8% de las recidivas eran metastásicas. CONCLUSIÓN: La localización del tumor no fue un factor pronóstico independiente en el cáncer de vesícula biliar T2. La colecistectomía extendida fue marginalmente superior que la colecistectomía simple. La cirugía radical debe incluir una resección hepática y una linfadenectomía adecuada.

Phase II trial of combination therapy of gemcitabine plus anti-angiogenic vaccination of elpamotide in patients with advanced or recurrent biliary tract cancer.

Background Elpamotide is an HLA-A*24:02-restricted epitope peptide of vascular endothelial growth factor receptor 2 (VEGFR-2) and induces cytotoxic T lymphocytes (CTLs) against VEGFR-2/KDR. Given the high expression of VEGFR-2 in biliary tract cancer, combination chemoimmunotherapy with elpamotide and gemcitabine holds promise as a new therapy. Patients and Methods Patients with unresectable advanced or recurrent biliary tract cancer were included in this single-arm phase II trial, with the primary endpoint of overall survival. Survival analysis was performed in comparison with historical control data. The patients concurrently received gemcitabine once a week for 3 weeks (the fourth week was skipped) and elpamotide once a week for 4 weeks. Results Fifty-five patients were registered, of which 54 received the regimen and were included in the full analysis set as well as the safety analysis set. Median survival was 10.1 months, which was longer than the historical control, and the 1-year survival rate was 44.4%. Of these patients, injection site reactions were observed in 64.8%, in whom median survival was significantly longer (14.8 months) compared to those with no injection site reactions (5.7 months). The response rate was 18.5%, and all who responded exhibited injection site reactions. Serious adverse reactions were observed in five patients (9%), and there were no treatment-related deaths. Conclusion Gemcitabine and elpamotide combination therapy was tolerable and had a moderate antitumor effect. For future development of therapies, it will be necessary to optimize the target population for which therapeutic effects could be expected.

Composite tissue transplantation in rats: fusion of donor muscle to the recipient site.

UNLABELLED: Little information currently exists on the repair of muscular tissue at the site of an amputation stump. This study examined the healing process of muscular tissue following composite limb transplantation using transgenic rat models. METHODS: Green fluorescent protein (GFP) transgenic rats were used to study the process of connection of donor muscle with the recipient. A DsRed2/GFP double-reporter transgenic rat and an NCre transgenic rat were used to study cell fusion. These rats have the unique characteristic of changing red fluorescence to green fluorescence by Cre/LoxP recombination when cell-to-cell fusion occurs between the two transgenic strains. Orthotopic hind limb transplantation was performed in two combinations: GFP transgenic rat to Wild Wistar rat and DsRed2/GFP transgenic rat to NCre transgenic rat. RESULTS: We observed extension of donor-derived GFP(+) myofibers into recipient site a few weeks after limb transplantation. A histologic study of the DsRed2/GFP transgenic rat to the NCre transgenic rat combination showed that red myofibers of the DsRed2/GFP rat were partly replaced by green myofibers as a result of Cre-mediated recombination. PCR analysis detected both the recombined transgene (330 bp) and the nonrecombined gene (1420 bp) in muscle around the junction. These findings indicate that the muscles sutured between the amputation stumps fused with each other and that donor-recipient hybrid cells were formed at the muscle junction following limb transplantation. CONCLUSIONS: This basic information shows muscle fusion between donor and recipient at the site of composite tissue transplant using newly established transgenic rats.

Transmigration of donor cells involved in the sciatic nerve graft.

INTRODUCTION: Recently, human hand transplantation in Europe has shown that motor function may be recovered in some cases. However, little is known about cell trafficking involved the graft nerve. We have succeeded to use green fluorescent protein transgenic (GFP-Tg) rats with various cells strongly expressing GFP in a model a long-term survival of limb graft. In this model, we found retrograde migration of GFP-positive donor cells through the sclatic nerve anastomosis. It is well known that cellular components in the peripheral nerve graft especially Schwann cells, play an important role in the axonal regeneration promoted by nerve grafting. However, it was difficult to distinguish the cellular component of the nerve graft from recipient cells. The purpose of this study was to evaluate the migration of donor origin cells to the recipient's nerve and to examine the contribution of these cells in axonal regeneration using a simplified model of sciatic grafting. METHODS: Nerve defects were created in recipient rats, using three experimental combinations: group 1: wild-type rats from GFP Tg rats; group 2: GFP Tg rats from wild-type rats; group 3: wild-type rats from GFP Tg rats whose nerve grafts had been pretreated by freeze-thawing cycles (representing an acellular graft). The sciatic nerve specimens were examined under excitation light at 1, 2, and 3 weeks after transplantation. RESULTS: GFP-positive area expanded clearly beyond the anastomosis both proximally and distally in group 1 and infiltrated into the middle of the null graft in group 2. On the contrary, freeze-thawing grafts donated GFP Tg rats lost GFP expression completely. Columns of GFP-positive cells were formed in the degenerated graft migrated into the recipient's nerve both ante- and retrograde. The S100-positive GFP-positive cells were considered to be graft-origin Schwann cells. The regenerating axons were accompanied with these double-positive cells in the recipient nerve. In conclusion, we have visualized the contribution of graft cells to axonal regeneration beyond a peripheral nerve anastomosis.

Can a bone marrow cell contribute to organ regeneration? In vivo analysis using transgenic rats with reporter genes.

Although implantation of multipotent bone marrow-derived stem cells represents an attractive new cell therapy to repair damaged tissues, recent reports have raised serious concerns over the feasibility of using stem cells deriving from the bone marrow to promote cell transdifferentiation. We established transgenic (Tg) rats with reporter genes as specific molecular tags to examine the effect of bone marrow cells (BMCs) on transdifferentiation into tissues/organs. To monitor transdifferentiation events of locally transplanted BMCs into hepatocytes or capillary endothelial cells, a liver injury model and an ischemic hind-limb model were developed in rats. To test the ability of circulating bone marrow-derived cells to give rise to myocytes after skeletal muscle injury, we used a bone marrow cell transplantation model from Tg rats, which showed ubiquitous expression of beta-galactosidase (lacZ), into lethally irradiated non-Tg rats. Our results show that there was little transdifferentiation of BMCs into the targeted cells in these tissue injury models. However, in the ischemic hind-limb model, laser Doppler imaging and histologic analysis showed that both implantation of BMCs and treatment with microspheres incorporating basic fibroblast-like growth factor (bFGF), which enables the release of bFGF at the site of action over a period of time, effectively induced angiogenesis. In conclusion, rat BMCs with specific marker genes could be a useful tool for detecting transdifferentiation events in vivo.

Gene gun-mediated oral mucosal transfer of interleukin 12 cDNA coupled with an irradiated melanoma vaccine in a hamster model: successful treatment of oral melanoma and distant skin lesion.

Malignant melanoma involving the oral cavity has a highly metastatic potential. Curative surgery is required to resect extensive oral tissues and often results in dysfunction as well as a severe cosmetic deformity in patients with the disease. An alternative technology for the local and sustained delivery of cytokines for cancer immunotherapy has been shown to induce tumor regression, suppression of metastasis, and development of systemic antitumor immunity. However, local immunization of the oral cavity has not previously been studied. In this study, we examined the efficacy of particle-mediated oral gene transfer on luciferase and green fluorescent protein production. The results showed that these proteins were more significantly expressed in oral mucosa than the skin, stomach, liver, and muscle. Using an established oral melanoma model in hamsters, particle-mediated oral gene gun therapy with interleukin (IL) 12 cDNA was then conducted. The results indicated that direct bombardment of mouse IL-12 cDNA suppressed tumor formation and improved the survival rate. The skin tumor model created by inoculation of melanoma cells was also significantly inhibited by the oral bombardment of IL-12 cDNA coupled with an irradiated melanoma vaccine administrated to the oral mucosa, compared to treatment with a percutaneous vaccine. IL-12 gene gun therapy, combined with an oral mucosal vaccine, induced interferon-gamma mRNA expression in the host spleen for a long time. These results suggest that immunization of oral mucosa may induce systemic antitumor immunity more efficiently than immunization of the skin and that oral mucosa may be one of the most suitable tissues for cancer gene therapy by means of particle-mediated gene transfer.

Enhancement of tumor uptakes by stabilized Fab homo-oligomers of a chimeric monoclonal antibody against carcinoembryonic antigen.

We investigated the effect of stabilized Fab oligomerization by disuccinimidyl suberate on tumor uptake in a pancreatic carcinoma xenograft model in nude mice. Recombinant mouse/human chimeric Fab of the anti-carcinoembryonic antigen (CEA) monoclonal antibody A10, which was previously shown to react specifically with gastrointestinal cancers was used in this study. Fab homo-oligomers (dimers and trimers) chemically linked with ethylene bonds (C-C oligomers) were produced by linkage of chimeric Fab. Oligomers with C-C bonds had similar immunoreactivity against human CEA to parental Fab monomer. In biodistribution studies in animals bearing pancreatic carcinoma xenografts, at 12 and 24 h after infusion, C-C oligomers showed significantly greater uptakes in tumors than Fab or F(ab')2 but lower than IgG. However, oligomers with C-C bonds maintained higher tumor to normal tissue specificity ratios than IgG 24 h post-infusion. In conclusion, tumor uptake was enhanced by Fab oligomerization with C-C bonds, compared to Fab or F(ab')2, perhaps due to the larger molecular size. It was also shown that C-C Fab oligomers could have a potency to deliver high-dose radionuclides with reduced radio-uptakes in normal tissues for the radioimmunotherapy of gastrointestinal carcinomas.

Expression of oncogene products and growth factors in early gallbladder cancer, advanced gallbladder cancer, and chronic cholecystitis.

The expression of oncogene products and growth factors (epidermal growth factor, transforming growth factor-beta, erbB-2, ras p 21, and c-myc) in gallbladder cancer and chronic cholecystitis was measured by immunohistochemical staining on paraffin-embedded serial sections. Expression of these products was graded according to staining intensity in an area of positively stained cells. This study reports the detection of oncogene products and growth factors in cholecystitis as well as in early and late gallbladder cancer. The multiexpression of oncogene products and growth factors was greater for both gallbladder cancer groups as compared with the cholecystitis group. The percentage of epidermal growth factor positivity diminished with increased proportion of interstitial tissue and, conversely, the percentage of transforming growth factor positivity increased with increased proportion of interstitial tissue. The proportion of ras positivity was significantly greater in both early and advanced cholecystic cancer as compared with cholecystitis, but also was considerable even for cholecystitis. These results suggest that various oncogenes may have significant roles in gallbladder cancer and that collagen synthesis is reduced by epidermal growth factor and enhanced by transforming growth factor-beta.

Ovarian small cell carcinoma with K-ras mutation: a case report with genetic analysis.

A rare case of ovarian small cell carcinoma is reported. Laboratory examination of a 46-year-old woman with a lower abdominal tumor showed marked hypercalcemia. Her condition deteriorated progressively, and she died one month after admission. A right ovarian tumor, 8 cm in diameter, metastases to multiple organs, and intraperitoneal bleeding were confirmed by autopsy. Microscopically, the small tumor cell had rounded nuclei with small distinct nucleoli and a scanty cytoplasm. Small cell carcinoma was diagnosed from these histological features and the clinical course associated with hypercalcemia. Immunohistochemical studies showed positive staining of neuron specific enolase (NSE) and keratin. Genetic analysis using DNA extracted from paraffin sections of metastatic lesions revealed mutation of K-ras codon 12. Loss of heterozygosity of the p53 and adenomatous polyposis coli (APC) genes was not informative. Previous reports have shown that ras gene mutations occur in 30% of epithelial ovarian tumors and significantly more frequently in mucinous than in other types of ovarian tumors. These results suggest that small cell carcinoma is of epithelial origin and may have a genetic alteration similar to that of mucinous tumors.

Ampullary carcinoma developing after androgenic steroid therapy for aplastic anemia: Report of a case.

Sex steroids influence the development and course of human genital carcinomas including breast, testis, prostata, and ovarian cancers. (1) Other carcinomas such as hepatoma, cholangioma, and pancreatic cancer have also been reported to be related to sex hormones. (2-4) The existence of sex hormone receptors has been demonstrated immunohistochemically in specimens of these diseases. We recently encountered a patient in whom an ampullary carcinoma developed 39 months after the start of androgenic steroid therapy for aplastic anemia. Immunohistochemic analysis of resected tumor specimens of the patient suggested a possible hormonal effect on the tumor oncology.

Biliary-enteric anastomosis by means of a single layer of serosubmucosal sutures without T-tube drainage.

BACKGROUND: To lessen anastomotic stricture after biliary-enteric anastomosis, we developed a new biliary-enteric anastomosis that uses a single layer of interrupted serosubmucosal sutures without T-tube drainage. OBJECTIVE: To evaluate the safety and reliability of this new technique in a canine model of choledochoduodenostomy. METHODS: In 10 beagles, the common bile duct (2 to 3 mm in diameter) was ligated close to the duodenum with 3-0 polyglactin. On the fifth day after operation, the serum bilirubin level was elevated (137 to 205 mumol/L [8 to 12 mg/dL]) and the bile duct was dilated. The anastomosis between serosubmucosal layers of the dilated bile duct (8 to 10 mm in diameter) and duodenum was accomplished with interrupted sutures of 6-0 polyglactin with two needles. Stitches were inserted in the submucosal plane at the cut edge of the duct and duodenum to appose the mucosa accurately and to avoid accidental perforation of the entire thickness of the duct and duodenum. A T tube was not placed. RESULTS: There was no anastomotic leakage and the bilirubin level was normalized (14 to 17 mumol/L [0.8 to 1.0 mg/dL]) 7 days after operation for anastomosis. Histologic examination of specimens removed 6 or 12 months after operation showed good connective-tissue union and good mucosal continuity between the bile duct and the duodenum. There was no mucosal scarring and contracture or stricture formation. CONCLUSION: This new technique is simple and reliable and is recommended as an alternative method for restoring the continuity between the bile duct and intestinal tract after operation for obstructive jaundice caused by benign and malignant stricture of the bile duct.

A new technique for pancreaticogastrointestinal anastomosis without suturing the pancreatic parenchyma.

BACKGROUND: In an attempt to lessen the incidence of pancreatic fistula and the disruption of pancreatic anastomosis after pancreatoduodenectomy, we have developed a new technique for pancreaticogastrointestinal anastomosis that consists of pancreatectomy using the ultrasonic dissector and implantation of the pancreatic duct into the gastrointestinal tract without suturing the pancreatic parenchyma. The purpose of this study is to evaluate the safety and reliability of this new technique in a canine model of pancreaticogastrostomy and pancreaticoduodenostomy using 10 beagle dogs. STUDY DESIGN: Canine pancreas was resected using the ultrasonic dissector. In the distal pancreas, a 1-cm long stump of the main pancreatic duct was freed and the other smaller pancreatic ducts were skeletonized and securely ligated. The main pancreatic duct was implanted into the stomach or the duodenum and fixed to the seromuscular layer with purse-string sutures without suturing the pancreatic parenchyma. RESULTS: There was no anastomotic leakage, signs of peritonitis, or abscess formation, and the pancreas was grossly normal in appearance seven days after operation. Histologic examination of the specimens harvested 30 days after operation revealed good connective tissue union between the pancreas and the gastric or duodenal wall, and good mucosal continuity between the pancreatic duct and the stomach or duodenum. CONCLUSIONS: This new technique is simple, safe, and reliable, and is recommended as an alternative method for restoring pancreaticogastrointestinal continuity after pancreatoduodenectomy.

Expression of thymidylate synthase in cancer of the ampulla of Vater.

The clinical and therapeutic significance of thymidylate synthase (TS) in cancers of the ampulla of Vater have not yet been reported. We immunohistochemically evaluated TS expression in 33 ampullary cancers using an anti-TS antibody. TS expression, clinicopathologic variables, and survival rates were examined and the correlations between these parameters were identified. Fifteen patients were found to express high levels of TS (high TS group), while 18 patients expressed low levels of TS (low TS group). No significant difference was found between TS expression and clinicopathologic factors. Univariate and multivariate analysis revealed that lymph node metastasis and pancreatic invasion are important variables for independently predicting post-operative survival. Although TS expression was not identified as an important factor for postoperative survival, recurrent cases in patients with chemotherapy existed only in the high TS group. In the present study, it was found that TS expression itself in cancers of the ampulla of Vater has no impact in predicting the prognosis of ampullary cancers, but a chemotherapeutic benefit of evaluating TS expression may exist.

The role of S100A4 gene encoding an S100-related calcium-binding protein in human bile duct adenocarcinoma cell lines: correlation of S100A4 expression and invasive growth in Matrigel Matrix.

S100A4, one of the tandemly arranged S100 genes at chromosome 1q21, has been suggested to play a functional role in cell motility and invasiveness of tumor cell growth. We investigated the expression of S100A4 and the in vitro invasiveness of 4 human bile duct adenocarcinoma cell lines by the Matrigel assay. S100A4 was abundantly expressed in 2 adenocarcinoma cell lines whose growth pattern was highly invasive. Induction of antisense S100A4 into one of the cell lines decreased S100A4 mRNA levels and reduced invasiveness. In contrast, induction of sense S100A4 expression into non-invasive KMBC adenocarcinoma cells, which originally lacked S100A4 expression, resulted in apparent invasive potential in the transfected cells compared with the cells with the vector alone. These results suggest that S100A4 expression is well correlated with the invasiveness of human bile duct adenocarcinomas.

A MEK inhibitor (U0126) markedly inhibits direct liver invasion of orthotopically inoculated human gallbladder cancer cells in nude mice.

Primary cancer of the gallbladder is not unusual. Most cases of gallbladder cancer are found at an advanced stage, accompanied by the invasion to the liver, metastases to the lymph nodes and distant organs, and peritoneal dissemination. In this study, we first examined the effect of mitogen-activated protein kinase kinase (MEK) inhibitors on the production of matrix metalloproteinases (MMPs), urokinase-type plasminogen activator (uPA), and tissue inhibitors of metalloproteinases (TIMPs) in a human gallbladder cancer cell line, NOZ cells in vitro. MEK inhibitors (PD98059 and U0126) inhibited the production of MMP-2, MMP-9 and high MW uPA, and upregulated TIMPs (TIMP-1, TIMP-2 and TIMP-3). Subsequently, we examined the effect of U0126 on invasion and metastasis of orthotopically inoculated NOZ cells in nude mice. Direct liver invasion by cancer cells was detected in all of the mice in the control group, but in only one mouse in the U0126-treated group. Most of the primary tumors in the U0126-treated group expanded to the liver, but did not invade into the liver. Vessel invasion in the liver was evident in 4 out of 5 mice in the control group, but in only one mouse in the U0126-treated group. Lymph node metastases and peritoneal dissemination were recognized in all of the mice in both groups. All 5 mice in the U0126-treated group, and 4 out of 5 mice in the vehicle control group, had metastases in the lungs. The present results suggest that a MEK inhibitor, U0126, prolonged the survival of the mice with NOZ tumor by inhibiting direct liver invasion and vessel invasion of the cancer cells via down-regulation of the matrix degrading ability of the cancer cells.

Surgical treatment for mucin-producing tumors of the pancreas.

BACKGROUND/AIMS: Our objectives in this study were to evaluate the surgical treatment for mucin-producing tumor of the pancreas from the clinicopathological and imaging features. METHODOLOGY: Thirty-one patients with mucin-producing tumor of the pancreas were examined based on clinicopathological analyses to determine the appropriate surgical treatment. RESULTS: The clinical and imaging features easily distinguished the main duct type of intraductal papillary lesions (type Ia), branch type of intraductal papillary lesions (type Ib) and mucinous cystic neoplasms (type II). From pathological examinations, a dilated main pancreatic duct had the malignant potentiality and multicentric development. CONCLUSIONS: Pancreatic segments containing a dilated main pancreatic duct should be resected in type Ia. Type Ib is sufficient for partial resection without lymphadenectomy. Type II also requires partial resection of the cystic neoplasm. A standard lymphadenectomy may be an option when type Ia and II show invasive features.

p53 protein expression and prognosis in gallbladder carcinoma and premalignant lesions.

BACKGROUND/AIMS: p53 protein expression in gallbladder carcinoma has recently been detected by immunohistochemical techniques, but the relationship between p53 expression and prognosis or clinico-pathological factors is still obscure. MATERIALS AND METHODS: We investigated 48 gallbladder carcinoma, 7 adenoma and 11 dysplasia cases for p53 expression by immunohistochemical techniques. RESULTS: p53 expression was positive in 39.6% of gallbladder cancer cases, but in no adenoma or dysplasia cases. No significant correlation was found between p53 overexpression and prognosis or recurrence in 20 patients with carcinoma involvement up to the subserosal layer. p53 overexpression was correlated with DNA aneuploidy pattern and the absence of stones, but was not correlated with clinical staging or lymph node metastasis. CONCLUSION: These results suggest that p53 gene mutation is related to the transition from premalignancy to malignancy in gallbladder carcinogenesis, as well as DNA ploidy alterations and carcinogenesis unassociated with gallstones, but has no bearing on the prognosis.

Proliferating cell nuclear antigen, p53, and c-erbB-2 expression in relation to clinicopathological variables and prognosis in cancer of the ampulla of Vater.

BACKGROUND/AIMS: Various clinicopathological factors have been thought to influence the prognosis of ampullary cancers. Recent advances in molecular biology should provide much useful information on the prognostic factors of ampullary carcinomas. METHODOLOGY: PCNA (proliferating cell nuclear antigen), p53, and c-erbB-2 were immunohistochemically evaluated in 30 resectable ampullary carcinomas. PCNA, p53, and c-erbB-2 expression, 6 clinicopathological variables, and prognosis were studied and correlations among these factors were investigated. RESULTS: The mean PCNA-positive rate was 39.1%. The percentages of cases positive for p53 and c-erbB-2 were 53% and 23%, respectively. No correlation was seen between PCNA, p53, or c-erbB-2 expression and clinicopathological variables. The optimum cut-off of PCNA indices influencing recurrence was decided as 40% by receiver operator characteristic curves. The cumulative disease-free survival rate of patients from the > or = 40% PCNA positive rate group was significantly poorer than that of the < 40% PCNA positive rate group (P < 0.01). p53 accumulation and c-erbB-2 expression were not correlated with prognosis. Multivariate analysis revealed that the PCNA positive rate and lymph node metastasis independently contributed to survival (P < 0.05). CONCLUSIONS: PCNA expression is a useful prognostic marker; however, p53 and c-erbB-2 overexpression are not useful as biomarkers for ampullary cancers.

Surgical results of operations for carcinoma of the gallbladder.

We evaluated the surgical results for carcinoma of the gallbladder. Between 1971 and 1995 we treated 258 patients, 74 of whom were treated with simple cholecystectomy, 71 with extended cholecystectomy, and 24 with more extended operations. The tumors were classified according to the stage proposed by the Japanese Society of Biliary Surgery. For m and pm carcinoma simple cholecystectomy may have an excellent result. However, it is difficult to know cancer depth exactly before or during operation, especially when combined with inflammation due to gallstones. In Stage I disease, extended cholecystectomy had an excellent result. So extended cholecystectomy is needed even in the early stage of the disease. Second operation is needed in inapparent carcinoma of the gallbladder if the tumor is more than pm or the margin is positive. More extended operations may be needed in advanced stages for curative resection. Extended hepatic lobectomy combined with pancreaticoduodenectomy should be indicated only if the patients are in good condition because of its high postoperative mortality and morbidity without a significant improvement in survival.

K-ras gene mutation related to histological atypias in human colorectal adenomas.

To investigate the relationship of oncogene analysis to morphology, we analyzed K-ras gene mutations by dot-blot hybridization with and without consideration of histological atypias in individual colorectal adenomas. Each of 54 colon polyps were divided into two parts after fixation. One part was used as a mass to assess point mutations; the remaining portion of each polyp was paraffin-embedded, stained with hematoxylin and eosin, and examined for point mutations related to histological atypias. In the first part of our study, K-ras gene mutations at codon 12 were detected in 13 cases (24%). In the second part of our study, 12 cases had distinctly different histological atypias. From each of these 12 cases, two areas, one with higher or one with lower grade atypia in the same polyp were excised to analyze for K-ras gene mutation. Two of these 12 cases (17%) had the mutation in different areas of the same tumor. These two cases contained the mutation only in the areas with higher grade atypia, and only one case added information regarding ras mutation upon microdissection when compared to the entire biopsy. These results suggest that oligonucleotide hybridization can identify the majority of cases containing ras mutations despite regional morphologic variation. Individual cases, however, may contain clonal subpopulations within adenomas with different ras sequences from other regions within the same adenoma.