Intra-abdominal bleeding caused by amyloid transthyretin amyloidosis in the gastrointestinal tract: a case report.

Diagnosis of gastrointestinal (GI) amyloidosis is often very difficult because of its nonspecific symptoms. However, a few reports have indicated that serious symptoms such as fatal GI bleeding and obstruction or perforation sometimes lead to a diagnosis of GI amyloidosis. A 79-year-old man was transported to our emergency department with a 1-week history of worsening abdominal pain. Abdominal contrast-enhanced computed tomography showed extravasation from part of the transverse colon wall and moderate ascites. Because intra-abdominal bleeding was suspected, the patient urgently underwent partial resection of the transverse colon, which was the source of the bleeding. Postoperative pathological examination of the tissue specimens led to a diagnosis of amyloid transthyretin amyloidosis. This is the first reported case in which intra-abdominal bleeding led to a diagnosis of GI amyloidosis. We should consider the possibility of GI amyloidosis when intraperitoneal bleeding is observed in elderly patients.

Far-advanced Colorectal Liver Metastases Successfully Managed With Modified ALPPS and Radiofrequency Ablation in Combination With Chemotherapy.

BACKGROUND: Large numbers of synchronous colorectal liver metastases are associated with poor prognosis. CASE REPORT: A 47-year-old male patient with rectal cancer and unresectable colorectal liver metastases (over 15 cm in diameter and over 30 metastases) was treated with a multidisciplinary treatment including systemic chemotherapy with mFOLFOX6/panitumumab and surgical therapies (colostomy, modified associating liver partition and portal vein ligation for staged hepatectomy together with radiofrequency ablation). For solitary recurrent colorectal liver metastases, percutaneous radiofrequency ablation with chemoembolization and open radiofrequency ablation in combination with the same systemic chemotherapy was performed. Since the diagnosis 3 years ago, he has been leading a good quality of life, free of any tumor or treatment. CONCLUSION: For patients with far-advanced but liver-only colorectal liver metastases, surgical therapy, systemic chemotherapy, and interventional treatment can be important for achieving good prognosis.

Construction and validation of a simple scoring system for stage III colorectal cancer recurrence (SiS-SCORE). A case control study.

BACKGROUND: Stage III colorectal cancer is an indication for adjuvant chemotherapy; however, there is no definite view on the selection of regimen. If the recurrence can be predicted, it can serve as the indicator of regimen selection. The present study aimed to predict the recurrence of stage III colorectal cancer by constructing a simple scoring system. METHODS: The information of stage III cases that underwent curative surgery was obtained from two facilities and analyzed. A scoring system was constructed from the analysis results and evaluated based on the cases from a different facility. RESULTS: Five factors were extracted by multivariate analysis: age > 65, male, rectum, ≥pN2 and CA19-9 > 37. When these parameters were scored as 1 point each, the score was correlated with the cumulative recurrence rate. Additionally, when cases were divided into three groups (≤1 point, 2 points, ≥3 points), the 5-year recurrence rate was as follows:, ≤1 point: 33.3%, 2 points: 42.1%, ≥3 points: 78.6%. The cumulative recurrence rate of ≥3 points was significantly higher than that of ≤1 point (P < 0.001). Similar results were obtained by evaluating that cases at a different facility (P = 0.032). Both cases with 2 points were located between ≤1 point and ≥3 points, reflecting the average recurrence rate of each institution. CONCLUSION: As the SiS-SCORE presented the same result in the facility that was different from the base facility, it can be used widely. However, a prospective study is required to prove the usefulness of the SiS-SCORE.

Internal hernia after laparoscopic right hemicolectomy, report of a case.

Mesenteric defects are often not closed in laparoscopic colectomy. We herein report a case of an internal hernia projecting through a mesenteric defect following laparoscopy-assisted right hemicolectomy. A 74-year-old woman was hospitalized for the surgical treatment of double colon cancer. Preoperative colonoscopy demonstrated the presence of ascending colon and transverse colon cancers. A laparoscopic-assisted right hemicolectomy was performed. The mesenteric defect resulting from the colectomy was not closed. Three months after the surgery, the patient developed a bowel obstruction. Under a diagnosis of strangulated bowel obstruction, we performed a laparotomy, and found a necrotic small bowel, which had passed into the bursa omentalis through the mesenteric defect. We removed the necrotic small bowel and closed the mesenteric defect by suturing. The patient's postoperative course was uneventful. An internal hernia projecting through a mesenteric defect following laparoscopy-assisted right hemicolectomy developed a severe strangulated bowel obstruction.

Hand-assisted laparoscopic spleen-preserving distal pancreatectomy combined with laparoscopic distal gastrectomy for the treatment of pancreatic neuroendocrine tumor with early gastric cancer: Report of a case.

INTRODUCTION: In a distal pancreatectomy combined with a distal gastrectomy, the splenic artery and vein must be conserved. However, it is not easy in pure laparoscopic surgery. We performed a hand-assisted laparoscopic spleen-preserving distal pancreatectomy (HALS-SPDP) combined with a laparoscopic distal gastrectomy (LDG) for the treatment of a pancreatic neuroendocrine tumor (NET) with early gastric cancer. PRESENTATION OF CASE: A 67-year-old male was hospitalized with no complaint. He was diagnosed with a pancreatic tail tumor (1.5cm in diameter) and early gastric cancer. He had undergone an endoscopic submucosal dissection (ESD). The pathohistology of the dissected tissue demonstrated that the histology was moderately differentiated adenocarcinoma, and the depth of the gastric cancer was pT1b2 (submucosal layer ∼1000µm). First, a pancreatectomy was performed extracorporeally under direct vision after detaching the spleen and the distal pancreas from the retroperitoneum under a hand-assisted laparoscopy. After the distal pancreatectomy, an LDG with a D1 lymphadenectomy was performed intracorporeally. The postoperative course was not eventful. Six months after surgery, an enhanced computed tomography (CT) scan revealed the patency of the splenic artery. CONCLUSION: An HALS-SPDP combined with an LDG is beneficial and safe for the patients who have a pancreatic benign or low-grade malignant tumor and gastric cancer.

[Protective effects of d-chlorpheniramine maleate pre-treatment against acute side effects of Irinotecan(CPT- 11)].

It is wellknown that cholinomimetic side effects, such as sedation, abdominal pain, nasal flow and watery eyes, may develop in patients in the early stage of Irinotecan (CPT-11) administration; however, there have been no investigations concerning methods for preventing the development of these side effects. To assess the protective effects of pre-treatment with d-CM on cholinomimetic side effects in the early stage after Irinotecan (CPT-11) administration, we prescribed d- Chlorpheniramine maleate (d-CM) to a group of patients prior to Irinotecan (CPT-11) administration. Twenty members from the group of non-d-CM-treated patients (n=39) and 4 members from the group of treated patients (n=20) complained of side effects. The pre-administration of d-CM significantly reduced the number of patients with side effects (p<0.05). The relative risk (RR) for the frequency of side effects was 0.39 (95% CI; 0.15-0.98), demonstrating that the frequency of side effects was significantly reduced. Based on theses findings, we concluded that the pre-administration of d-CM had protective effects against side effects that might develop in the early stage after Irinotecan (CPT-11) administration.

Treatment results of FOLFOX chemotherapy before surgery for lymph node metastasis of advanced colorectal cancer with synchronous liver metastasis: the status of LN metastasis and vessel invasions at the primary site in patients who responded to FOLFOX.

PURPOSE: The combination of chemotherapy and surgery holds promise for improving CRC patient prognosis. We evaluated the pathological impact of chemotherapy on primary lesions and lymph node (LN) metastases retrospectively. METHODS: Sixteen CRC patients with synchronous liver metastasis underwent a radical operation between March 2005 and August 2007. Eight of the 16 cases (surgery group) were operated on for the primary lesion without chemotherapy and another 8 cases (chemotherapy group) were operated on after chemotherapy with FOLFOX (median: 8 courses). RESULTS: Five of the 8 patients in the surgery group were found to have pathological LN metastasis (62.5%; N0 37.5%, N1 37.5%, N2 25%). However, only 2 of the 8 patients in the chemotherapy group were found to have LN metastasis (25%; N0 75%, N1 25%, N2 0%). The ratio of LN metastasis (number of metastatic LNs/resected LNs in total) was 11.1% in the surgery group, but it was 4.8% in the chemotherapy group. Necrotic areas were widely detected in the LN specimens of the chemotherapy group. The percentage of lymphatic (ly) and vascular (v) invasion in the primary lesions was smaller in the chemotherapy group (ly 12.5% vs. 25.0%) than in the surgery group (ly 62.5% vs. 50.0%). The patients in the chemotherapy group had no significant adverse effects and did not show an worse survival rate overall than the surgery group. CONCLUSIONS: A promising effect of chemotherapy on the status of LN metastasis and vessel invasions at the primary site was observed in the patients who responded to FOLFOX.

K858, a novel inhibitor of mitotic kinesin Eg5 and antitumor agent, induces cell death in cancer cells.

The aim of this study was to investigate the mechanism of inhibition of Eg5 (kinesin spindle protein), a mitotic kinesin that plays an essential role in establishing mitotic spindle bipolarity, by the novel small molecule inhibitor K858. K858 was selected in a phenotype-based forward chemical genetics screen as an antimitotic agent, and subsequently characterized as an inhibitor of Eg5. K858 blocked centrosome separation, activated the spindle checkpoint, and induced mitotic arrest in cells accompanied by the formation of monopolar spindles. Long-term continuous treatment of cancer cells with K858 resulted in antiproliferative effects through the induction of mitotic cell death, and polyploidization followed by senescence. In contrast, treatment of nontransformed cells with K858 resulted in mitotic slippage without cell death, and cell cycle arrest in G(1) phase in a tetraploid state. In contrast to paclitaxel, K858 did not induce the formation of micronuclei in either cancer or nontransformed cells, suggesting that K858 has minimal effects on abnormalities in the number and structure of chromosomes. K858 exhibited potent antitumor activity in xenograft models of cancer, and induced the accumulation of mitotic cells with monopolar spindles in tumor tissues. Importantly, K858, unlike antimicrotubule agents, had no effect on microtubule polymerization in cell-free and cell-based assays, and was not neurotoxic in a motor coordination test in mice. Taken together, the Eg5 inhibitor K858 represents an important compound for further investigation as a novel anticancer therapeutic.

"Tornado Roux-en-Y" anastomosis in laparoscopy-assisted distal gastrectomy.

The use of laparoscopy-assisted distal gastrectomy has been gradually spreading and it has become one of the standard treatment options for early gastric cancer in Japan. But anastomotic problems are still frequent with this procedure, because of its technical difficulty. We have developed a simple, safe, and speedy Roux-en-Y anastomosis for use in laparoscopy-assisted distal gastrectomy. Here, we describe our technique and the short-term results.

A patient with 43 synchronous early gastric carcinomas with a Krukenberg tumor and pericardial metastasis.

A 53-year-old Japanese woman with bilateral ovarian tumors consulted our department. Gastroendoscopy disclosed 16 superficial depressed gastric lesions, and the histopathological diagnosis of the biopsy specimens was poorly differentiated adenocarcinoma and signet-ring cell carcinoma. Computed tomography (CT), ultrasonography (US), and positron emission tomography (PET) examinations revealed no other metastasis except for that observed in the ovaries. We performed a total gastrectomy with radical lymph node dissection and bilateral ovarian resection. A postoperative histological examination revealed 43 isolated gastric lesions which were scattered over the entire resected stomach; they were all confined to the mucosa. Cancer cell invasion in the lymphatics was detected only in the submucosal region beneath the main tumor. Both ovarian tumors were diagnosed as metastasis of signet-ring cell carcinoma (Krukenberg tumor). Adjuvant chemotherapy with irinotecan (CPT-11) and low-dose cisplatin (CDDP) was given on an outpatient basis, but 1 year after the surgery, carcinomatous pericarditis occurred. Administration of mitomycin C (MMC) into the pericardial space was performed twice; however, unfortunately, the patient died 13 months after surgery.

Indications for EMR/ESD in cases of early gastric cancer: relationship between histological type, depth of wall invasion, and lymph node metastasis.

BACKGROUND: Limited surgery by endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) for gastric cancer is frequently performed in many institutions. These techniques do preserve gastric function and maintain a high quality of life but may compromise survival. The treatment strategy for early tumors should therefore be based on a complete cure, and limited surgery must thus have clear indications. METHODS: D2 gastric resection was performed in 278 early gastric adenocarcinomas, and a retrospective histological review of the specimens was made. The extended indications for EMR or ESD, according to the Japanese Gastric Cancer Association Treatment guidelines for gastric cancer in Japan, were also assessed. RESULTS: Of the 278 early gastric cancers, 115 were mucosal (M) cancers without ulcer. No lymph node metastases were seen in these specimens. Six of the 41 specimens of M cancer with ulcers had lymph node metastases at the N1 level only. One of these had lymph node metastases from a tumor measuring less than 3 cm in size. Twenty-eight of 122 submucosal cancers had lymph node metastases (23%). Twenty of these were SM1 tumors and 5 had lymph node metastases; 4 of these 5 had lymph node metastases despite the absence of vascular invasion. CONCLUSION: Three cases had lymph node metastases that met the extended criteria for EMR/ESD. EMR and/or ESD should be limited to M cancers without ulcer or differentiated-type M cancer with ulcers smaller than 2 cm. When the depth of tumor invasion is deeper than M, then a gastric resection with lymph node dissection is necessary.

Cytoplasmic expression of type VII collagen is related to prognosis in patients with esophageal squamous cell carcinoma.

OBJECTIVE: Type VIIcollagen, the major component of anchoring fibrils, has been suggested to be involved with tumor cell invasion in a laminin-5-dependent manner in skin squamous cell carcinoma. However, the significance of type VII collagen expression in esophageal squamous cell carcinoma (ESCC) has been unknown to date. Therefore, we examined the expression of type VIIcollagen in ESCC, and confirmed the association between type VIIcollagen expression and clinicopathologic characteristics. METHODS: We immunohistochemically examined the expression of type VII collagen and laminin-5 gamma2 chain in surgical specimens of primary tumors in 109 patients with ESCC. RESULTS: Positive cytoplasmic expression of type VII collagen was detected in 35%. Significant correlation between the expression of type VII collagen and laminin-5 gamma2 chain expression was observed. In the type VII collagen-negative group, the 5-year survival rate was significantly better than in the positive group. Multivariate analysis indicated that the positive expression of type VII collagen was an independent prognostic factor. CONCLUSIONS: The expression of type VII collagen was closely related to poor prognosis. Type VII collagen cytoplasmic expression could be a useful marker for evaluating the tumor cell properties, including prognosis, in patients with ESCC.

The tumor suppressor WARTS activates the Omi / HtrA2-dependent pathway of cell death.

Drosophila tumor suppressor WARTS (Wts) is an evolutionally conserved serine / threonine kinase and participates in a signaling complex that regulates both proliferation and apoptosis to ensure the proper size and shape of the fly. Human counterparts of this complex have been found to be frequently downregulated or mutated in cancers. WARTS, a human homolog of Wts, is also known as tumor suppressor and mitotic regulator, but its molecular implications in tumorigenesis are still obscure. Here, we show that WARTS binds via its C-terminus to the PDZ domain of a proapoptotic serine protease Omi / HtrA2. Depletion of WARTS inhibited Omi / HtrA2-mediated cell death, whereas overexpression of WARTS promoted this process. Furthermore, WARTS can enhance the protease activity of Omi / HtrA2 both in vivo and in vitro. Activation of Omi / HtrA2-mediated cell death is thus a potential mechanism for the tumor suppressive activity of WARTS.

Spindle checkpoint function is required for mitotic catastrophe induced by DNA-damaging agents.

Mitotic catastrophe is an important mechanism for the induction of cell death in cancer cells by antineoplastic agents that damage DNA. This process is facilitated by defects in the G1 and G2 checkpoints of the cell cycle that are apparent in most cancer cells and which allow the cells to enter mitosis with DNA damage. We have now characterized the dynamics of mitotic catastrophe induced by DNA-damaging agents in p53-deficient cancer cells. Cells that entered mitosis with DNA damage transiently arrested at metaphase for more than 10 h without segregation of chromosomes and subsequently died directly from metaphase. In those metaphase arrested precatastrophic cells, anaphase-promoting complex appeared to be inactivated and BubR1 was persistently localized at kinetochores, suggesting that spindle checkpoint is activated after the DNA damage. Furthermore, suppression of spindle checkpoint function by BubR1 or Mad2 RNA interference in the DNA damaged cells led to escape from catastrophic death and to subsequent abnormal mitosis. Dysfunction of the spindle checkpoint in p53-deficient cancer cells is thus likely a critical factor in resistance to DNA-damaging therapeutic agents.

Tumor suppressor WARTS ensures genomic integrity by regulating both mitotic progression and G1 tetraploidy checkpoint function.

Defects in chromosomes or mitotic spindles activate the spindle checkpoint, resulting in cell cycle arrest at prometaphase. The prolonged activation of spindle checkpoint generally leads to mitotic exit without segregation after a transient mitotic arrest and the consequent formation of tetraploid G(1) cells. These tetraploid cells are usually blocked to enter the subsequent S phase by the activation of p53/pRb pathway, which is referred to as the G(1) tetraploidy checkpoint. A human homologue of the Drosophila warts tumor suppressor, WARTS, is an evolutionarily conserved serine-threonine kinase and implicated in development of human tumors. We previously showed that WARTS plays a crucial role in controlling mitotic progression by forming a regulatory complex with zyxin, a regulator of actin filament assembly, on mitotic apparatus. However, when WARTS is activated during cell cycle and how the loss of WARTS function leads to tumorigenesis have not been elucidated. Here we show that WARTS is activated during mitosis in mammalian cells, and that overexpression of a kinase-inactive WARTS in Rat1 fibroblasts significantly induced mitotic delay. This delay resulted from prolonged activation of the spindle assembly checkpoint and was frequently followed by mitotic slippage and the development of tetraploidy. The resulting tetraploid cells then abrogated the G(1) tetraploidy checkpoint and entered S phase to achieve a DNA content of 8N. This impairment of G(1) tetraploidy checkpoint was caused as a consequence of failure to induce p53 expression by expressing a kinase-inactive WARTS. WARTS thus plays a critical role in maintenance of ploidy through its actions in both mitotic progression and the G(1) tetraploidy checkpoint.

Activation of m-calpain is required for chromosome alignment on the metaphase plate during mitosis.

Calpains form a superfamily of Ca(2+)-dependent intracellular cysteine proteases with various isoforms. Two isoforms, micro- and m-calpains, are ubiquitously expressed and known as conventional calpains. It has been previously shown that the mammalian calpains are activated during mitosis by transient increases in cytosolic Ca(2+) concentration. However, it is still unknown whether the activation of calpains contributes to particular events in mitosis. With the use of RNA interference (RNAi), we investigated the roles of calpains in mitosis. Cells reduced the levels of m-calpain, but not mu-calpain, arrested at prometaphase and failed to align their chromosomes at the spindle equator. Specific peptidyl calpain inhibitors also induced aberrant mitosis with chromosome misalignment. Although both m-calpain RNAi and calpain inhibitors affected neither the separation of centrosomes nor the assembly of bipolar spindles, Mad2 was detected on the kinetochores of the misaligned chromosomes, indicating that the prometaphase arrest induced by calpain inhibition is due to activation of the spindle assembly checkpoint. Furthermore, when calpain activity was inhibited in cells having monopolar spindles, chromosomes were clustered adjacent to the centrosome, suggesting that calpain activity is involved in a polar ejection force for metaphase alignment of chromosomes. Based on these findings, we propose that activation of m-calpain during mitosis is required for cells to establish the chromosome alignment by regulating some molecules that generate polar ejection force.

CENP-A phosphorylation by Aurora-A in prophase is required for enrichment of Aurora-B at inner centromeres and for kinetochore function.

The Aurora (Ipl1)-related kinases are universal regulators of mitosis. We now show that Aurora-A, in addition to Aurora-B, regulates kinetochore function in human cells. A two-hybrid screen identified the kinetochore component CENP-A as a protein that interacts with Aurora-A. Aurora-A phosphorylated CENP-A in vitro on Ser-7, a residue also known to be targeted by Aurora-B. Depletion of Aurora-A or Aurora-B by RNA interference revealed that CENP-A is initially phosphorylated in prophase in a manner dependent on Aurora-A, and that this reaction appears to be required for the subsequent Aurora-B-dependent phosphorylation of CENP-A as well as for the restriction of Aurora-B to the inner centromere in prometaphase. Prevention of CENP-A phosphorylation also led to chromosome misalignment during mitosis as a result of a defect in kinetochore attachment to microtubules. Our observations suggest that phosphorylation of CENP-A on Ser-7 by Aurora-A in prophase is essential for kinetochore function.

Aurora-A kinase maintains the fidelity of early and late mitotic events in HeLa cells.

Aurora-A, a member of the Aurora/Ipl1-related kinase family, is overexpressed in various types of cancer and considered to play critical roles in tumorigenesis. To better understand the pathological effect of Aurora-A activation, it is first necessary to elucidate the physiological functions of Aurora-A. Here, we have investigated the roles of Aurora-A in mitotic progression with the small interfering RNA, antibody microinjection, and time lapse microscopy using human cells. We demonstrated that suppression of Aurora-A by small interfering RNA caused multiple events to fail in mitosis, such as incorrect separation of centriole pairs, misalignment of chromosomes on the metaphase plate, and incomplete cytokinesis. Antibody microinjection of Aurora-A into late G2 cells induced dose-dependent failure in separation of centriole pairs at prophase, indicating that Aurora-A is essential for proper separation of centriole pairs. When we injected anti-Aurora-A antibodies into prometaphase cells that had separated their centriole pairs, chromosomes were severely misaligned on the metaphase plate, indicating that Aurora-A is required for proper movement of chromosomes on the metaphase plate. Furthermore, inhibition of Aurora-A at metaphase by microinjected antibodies prevented cells from completing cytokinesis, suggesting that Aurora-A also has important functions in late mitosis. These results strongly suggest that Aurora-A is essential for many crucial events during mitosis and that the phosphorylation of a series of substrates by Aurora-A at different stages of mitosis may promote diverse critical events in mitosis to maintain chromosome integrity in human cells.