Identification and characterization of genes associated with human hepatocellular carcinogenesis.

Eight cDNAs encoding galectin 4 (Gal-4), UGT2B4 (UDP-glucuronosyltransferase), ribosomal phosphoprotein P0 (rpP0), dek, insulin-like growth factor binding protein (IGFBP) 1, vitronectin, retinoic acid-induced gene E (RIG-E), and CYP3A4 (cytochrome P450 nifedipine oxidase) were identified as differentially expressed genes between human hepatocellular carcinoma (HCC) and matched nontumorous liver tissues. Higher levels of UGT2B4, rpP0, dek, vitronectin, Gal-4, and IGFBP-1 mRNAs combined with a lower level of RIG-E mRNA were observed in at least four of five primary HCCs compared to matched nontumorous liver tissues. Furthermore, a pathological study suggested that the levels of UGT2B4, rpP0, dek, and vitronectin increased and the level of RIG-E decreased with the histological grading. On the other hand, the expression of CYP3A4 mRNA and CYP3A7 (P-450 Fla) mRNA, a transcript found in the fetus and highly homologous to CYP3A4, was higher in all nontumorous liver and some of the carcinoma tissues from five HCC patients, whereas it was significantly lower in normal liver tissues from two non-HCC patients. The examination using HCC cell lines HuH-7 and HepG2 under different growth conditions suggested that the expression of dek mRNA was growth-associated. In contrast, the expression of Gal-4, UGT2B4, IGFBP-1, and RIG-E mRNAs was regulated in a cell density-dependent manner: the levels of Gal-4, UGT2B4, and IGFBP-1 were undetectably low, whereas the level of RIG-E was high in rapidly proliferating, subconfluent HCC cells in 10% serum; however, the expression levels were reversed in dense, overcrowded cultures. In addition, IGFBP-1 and Gal-4 mRNAs were also induced by reducing the serum concentration to 0.1%. We also demonstrated that sodium butyrate, an inducer of differentiation, up-regulated and down-regulated RIG-E and dek mRNAs, respectively, in a dose-dependent manner in HuH-7 cells, supporting, in part, our pathological observation. In summary, therefore, high expression of Gal-4, UGT2B4, rpP0, dek, IGFBP-1, and vitronectin, together with low expression of RIG-E, was correlated with the malignant potential of HCC. CYP3A4 and CYP3A7 could be induced in HCC-bearing livers. These transcripts are differentially regulated depending on cell-cell contact, serum growth factors, growth and differentiation status, and/or other mechanisms in premalignant and malignant liver cells.

Enhanced expression of mRNAs of antisecretory factor-1, gp96, DAD1 and CDC34 in human hepatocellular carcinomas.

To identify differentially expressed genes in hepatocarcinogenesis, we performed differential display analysis using surgically resected hepatocellular carcinoma (HCC) and adjacent non-tumorous liver tissues. We identified four cDNA fragments upregulated in HCC samples, encoding antisecretory factor-1 (AF), gp96, DAD1 and CDC34. Northern blot analysis demonstrated that these mRNAs were expressed preferentially in HCCs compared with adjacent non-tumorous liver tissues or normal liver tissues from non-HCC patients. The expression of these mRNAs was increased along with the histological grading of HCC tissues. These mRNA levels were also high in three human HCC cell lines (HuH-7, HepG2 and HLF), irrespective of the growth state. We also demonstrate that sodium butyrate, an inducer of differentiation, downregulated the expression of AF and gp96 mRNAs, supporting in part our pathological observation. Immunohistochemical analysis revealed that gp96 and CDC34 proteins were preferentially accumulated in cytoplasm and nuclei of HCC cells, respectively. Overexpression of these genes could be an important manifestation of HCC phenotypes and should provide clues to understand the molecular basis of hepatocellular carcinogenesis.

Spatial arrangement of the pancreatic ducts in the head of the pancreas with special reference to the branches of the uncinate process.

BACKGROUND: It remains very difficult to clarify the spatial arrangement of the branches of the pancreatic ducts in the head of the pancreas despite recent progress in diagnostic imaging techniques. METHODS: We minutely dissected the head region from 15 cadavers after injection of silicone rubber into the ducts through the papilla of Vater to investigate the distribution of these ducts. RESULTS: We found that the branches that drained the uncinate process not only joined the main pancreatic duct but also constantly joined the accessory pancreatic duct. In addition, the branches of the uncinate process that joined the accessory duct ran anterior to those to the main duct. We classified the arrangement of the pancreatic ducts into type 1 (10 cases) and type 2 (5 cases) on the basis of the pattern of the branches of the uncinate process. The distance from the papilla of Vater to the junction of the main and accessory pancreatic ducts in type 1 (> 23.0 mm) was significantly longer than that in type 2 (< 22.0 mm). CONCLUSIONS: Careful attention should be paid to the branches of the uncinate process to the accessory pancreatic duct to enable more accurate diagnoses of the pancreas head region.

Esophageal carcinoma and coexisting hepatocellular carcinoma resected simultaneously.

We have experience with two cases in which esophageal carcinoma and coexisting hepatocellular carcinoma were resected simultaneously. One patient had advanced esophageal carcinoma located in the thoracic esophagus and solitary hepatoma in the posterior segment of the liver with normal liver function. The other patient had superficial esophageal carcinoma in the thoracic esophagus and solitary hepatoma in the posterior segment of the liver with impaired liver function. Subtotal resection of the esophagus and posterior segmentectomy of the liver were performed simultaneously in both patients. In the patient with impaired liver function, postoperative management of respiration and bleeding was difficult, and intensive care was needed. Mediastinal lymph node resection was modified. Postoperative course was considered to have a close relationship to liver function. Thus, close evaluation of liver function is important to decide suitable treatment of patients with primary hepatocellular carcinoma and coexisting malignant neoplasms. With close evaluation of liver function and intensive postoperative care, simultaneous resection of esophageal carcinoma and hepatocellular carcinoma is not impossible or difficult.

Hepatic resection under the intermittent selective portal branch occlusion by balloon catheter.

BACKGROUND: In hepatic resection, it is important to control intrahepatic blood flow to minimize blood loss. Intermittent and selective vascular occlusion, if possible, are advisable. STUDY DESIGN: For this purpose, we created the double balloon catheter, which when introduced into a lobar or a smaller branch of the intrahepatic portal vein through a branch of the ileocolic vein, made it possible to occlude these branches temporarily during hepatic resection. The small balloon located at the tip of the catheter made it easy to introduce the catheter to the portal branch selectively, under the guidance of ultrasonography. Another balloon was inflated intermittently to occlude selective portal blood flow. Using this technique, hepatic resection was achieved in 18 consecutive patients: 13 with hepatocellular carcinomas (11 with cirrhosis, two with chronic hepatitis), one with cholangiocellular carcinoma, three with metastatic carcinomas, and one with intrahepatic calculi. RESULTS: In these cases, 19 hepatic resections were performed; two left hepatectomies, one extended right hepatectomy, one right hepatectomy, six segmentectomies, eight subsegmentectomies, and one partial hepatectomy. In each case, well demarcated hepatic tissue delineated by ischemic change was removed with minimal bleeding and little impairment to the residual hepatic tissue, resulting in a good postoperative course. CONCLUSIONS: This double balloon catheter can replace the dissection of the hepatoduodenal ligament for hepatic resection, which causes bleeding, especially in patients with cirrhosis, and results in less cell injury of the residual hepatic parenchyma.

Morphological changes in gastric carcinoma with progression.

By combining morphological two indices, namely, (1) the degree of differentiation of glandular tubules (well or poor) and (2) the amount of intracellular mucus (rich or poor), we previously classified histological types of gastric carcinoma into four types. Using this histological classification, we studied the morphological changes of gastric carcinoma according to extra-gastric invasion in 200 autopsy and 200 resected cases. In cases in which the predominant histological type in the lamina propria was "tubular differentiation--well, mucus in cytoplasm--poor," there was a greater incidence of co-existence with other histological types. In many of these cases, the predominant histological findings changed to "tubular differentiation--poor" in the subserosa, followed by direct invasion into neighboring extra-gastric tissues. In all cases in which the predominant histological type in the lamina propria was "tubular differentiation--poor," the predominant histological type in the subserosa was also "tubular differentiation--poor." To understand the mode of extension of gastric carcinoma in relation to the histological type, we must consider not only the characteristics of the predominant histological types of carcinoma but also those of co-existing types, especially in cases of "tubular differentiation--well, mucus in cytoplasm--poor."

Giant epiphrenic diverticulum with achalasia occurring 20 years after Heller's operation.

We report a case of giant epiphrenic diverticulum in a 43-year-old woman who underwent Heller's myotomy because of achalasia 20 years earlier. She complained of heartburn and dysphagia from March of 1991 and was hospitalized in our institution. An upper gastrointestinal X-ray examination with contrast medium revealed a large hemispheric lesion (7.8 x 4.8 cm) occupying the right posterior wall of the lower thoracic and abdominal esophagus. Manometry revealed a motility disorder and high pressure of the lower esophageal sphincter due to achalasia. Therefore she was diagnosed as having a giant diverticulum with achalasia after Heller's operation. She underwent transhiatal esophagectomy and reconstruction with placement of a gastric tube on June 4, 1992. Pathology results on the resected specimen revealed a false diverticulum. She has been doing well for 4 years since the operation. It has been said that a complication of incomplete long myotomy causes pulsion diverticulum, but we could not find a case of epiphrenic diverticulum after myotomy for achalasia reported in the literature in the last 10 years.

Doxorubicin and vincristine with methionine depletion contributed to survival in the Yoshida sarcoma bearing rats.

Several anti-cancer agents show increased toxicity if administered with methionine-depleting total parenteral nutrition (Met-deplete TPN). Changes in the cell cycle due to Met-deplete TPN were investigated, and then the enhancement of the anti-tumor effects of serial combinations of doxorubicin (ADM), a drug acting on late S-G2 phase and vincristine (VCR), an antimitotic drug, under Met-deplete TPN was also examined in the tumor-bearing rats. According to the fraction of labeled mitosis, within 3 to 4 days after the introduction of Met-deplete TPN in the ascites type Yoshida sarcoma (YS) -bearing rats, the cell cycle of the tumor cells showed marked delay and the fraction of labeled mitosis decreased to less than 70%. However, this delay was recovered immediately after methionine infusion, with on increase in the labeled mitotic cell population. In the experiment using solid type YS-bearing rats, ADM was administered intraperitoneally under Met-deplete TPN for 8 days, followed by intraperitoneal VCR administration with methionine-containing TPN for 3 days, and then fed on solid food and water ad libitum until death. This serial combination of Met-deplete TPN with ADM and VCR resulted in marked suppression of the tumor and prolonged survival in comparison to the control groups with a significant difference (p < 0.001) (generalized Wilcoxon test).

Enhanced expression of translation factor mRNAs in hepatocellular carcinoma.

Several studies have demonstrated elevated expression of translation factor mRNAs in malignant tissues. In this study, using primary human hepatocellular carcinoma (HCC) tissues, we examined gene expression of translation factors, including 2 eukaryotic initiation factors (eIFs-4A1, -4E), 4 elongation factors (eEFs-1 alpha, -1 gamma, -1 delta, and -2) and 10 ribosomal proteins (Rps P1, P2, S10, L35, L5, L39, L9, L6, S3a and S17), whose mRNA expression has never been examined in HCC. Our results demonstrated that all the mRNAs examined were up-regulated in HCC tissues. Among 7 HCC tissues of different histological grades, the expression of these mRNAs remained at basal levels in a well to moderately differentiated (W/M-) HCC, was coordinately up-regulated in moderately differentiated (M-) HCCs. In moderately to poorly differentiated (M/P-) HCCs, the expression of eEFs-1 gamma, -1 delta, -2, Rps P0 and L9 mRNAs was further up-regulated along with the histological grading. These results therefore suggest that coordination and specific activation of translation factor genes might be involved in the process of liver carcinogenesis.

Laparoscopic enucleation of an insulinoma of the pancreas tail.

A 29 year-old woman with a tumor of the pancreatic tail was referred to our institute. The tumor was confirmed to be a solitary benign insulinoma that protruded from the pancreas and was distant from the main pancreatic duct. A laparoscopic enucleation was performed with Laparoscopic Coagulating Shears (LCS). The postoperative course was uneventful. The laparoscopic enucleation for benign pancreatic tumor was thought to be a feasible procedure when the appropriate instruments were used.

Hassab operation with intraoperative endoscopic injection sclerotherapy ("Hassab-EIS") for esophagogastric varices: with an autopsied case after excessive gastric vascular damage.

BACKGROUND/AIMS: Endoscopic injection sclerotherapy (EIS) does not always treat advanced esophagogastric varices completely. Moreover, it may cause deterioration of gastric varices and may result in gastric hemorrhages. We would like to emphasize a combination treatment of the obliteration therapy of intramural varices by EIS and the transabdominal devascularization with splenectomy by Hassab's operation for such advanced esophagogastric varices. The purpose of this study is to develop an effective, less-painful procedure, having the fewest operational risks and a minimum number of treatment days. MATERIALS AND METHODS: We tried both therapies simultaneously (Hassab+EIS) on four patients with esophagogastric varices. RESULTS: Excessive vessel damage occurred in one patient which resulted in postoperative bleeding. He subsequently fell into sepsis/DIC and eventually died on the 9th POD. The three other patients are doing well and required less hospitalization time and a fewer number of additional EIS treatments than the esophageal transection group or the Hassab's operation group. CONCLUSION: From the reconsideration of the autopsied case, it is important to limit the distribution of the sclerosant only in the varicose veins of the lower esophagus and the upper stomach.

Procedures of simultaneous radical resection indicated for primary synchronous esophageal and liver cancers--from the personal experience of three cases.

Primary double cancers of the liver and esophagus are extremely rare. Only 7 cases, both cancers resected, were reported. A 2 stage surgical procedure has been recommended for such a case. We experienced 3 consecutive patients who underwent successful simultaneous radical resection with a good outcome. Case 1 with an advanced esophageal cancer (EC) and hepatocellular carcinoma (HCC) without liver dysfunction received subtotal esophagectomy and posterior segmentectomy of the liver under a thoraco-laparotomy. Case 2, with an early stage EC and HCC with Child A cirrhosis, received the same surgical procedures as case 1 to complete stanching under good visibility for esophagectomy, because of his bleeding tendency due to liver dysfunction. But post operative bleeding from the thoracic cavity continued for 5 consecutive postoperative days. Case 3, with an early stage EC and cholangiocellular carcinoma (CCC), underwent transhiatal esophagectomy and right hepatic lobectomy under laparotomy. All cases received active enteral nutritional (EN) support from the early postoperative day with good outcomes. In conclusion, simultaneous radical resection for synchronous cancers of the esophagus and liver might be a possible indication for patients who have little or slight liver dysfunction. In the case with liver dysfunction, esophagectomy should be performed under thoracotomy, but transhiatal resection, for complete stanching, even in the early stage EC. Post-operative EN support is essential for these patients to obtain a good outcome.

Multiple endocrine neoplasia type 1 associated with spinal ependymoma.

A 51-year-old man was hospitalized with a gait disturbance and hypoesthesia below the level of his chest. These symptoms were due to a spinal tumor which was surgically resected and identified as an ependymoma. Additionally, the patient had hypercalcemia and a family history of insulinoma. An endocrine evaluation revealed parathyroid hyperplasia and a pancreatic islet cell tumor. Magnetic resonance imaging disclosed a pituitary microadenoma. He was diagnosed with spinal ependymoma and multiple endocrine neoplasia type 1 (MEN 1). A review of the literature revealed that chromosome 11q13 abnormalities have been reported in both ependymoma and MEN 1. We discuss the pathogenesis of these diseases.

[Intraperitoneal administration of CPT-11 in rats--experimental study for pharmacokinetics].

The pharmacokinetics of CPT-11 administered into rats to evaluate the future possibility of i.p. administration was investigated. Serum, bile juice, and intraperitoneal fluid was collected to measure the concentration of CPT-11, its metabolite SN-38, and SN-38 glucuronized (SN-38 glu). The concentration of CPT-11 was elevated after CPT-11 administration into the peritoneal cavity. The serum and biliary concentrations of SN-38 and SN-38 glu were increased and prolonged shortly after i.p. administration of CPT-11. These results suggest the possibility of i.p. administration of CPT-11 in the future.

[Clinical evaluation of anticancer effect of methionine-depleting total parenteral nutrition with 5-fluorouracil and/or mitomycin C].

Methionine-depleting total parenteral nutrition (Met-deplete TPN), infusing AO-90 amino acid solution (lacking both L-methionine and L-cysteine) as a sole nitrogen source, showed synergistic effects with several antineoplastics including 5-fluorouracil (5-FU). In the recent multi-center, randomized, controlled study, advanced gastric cancer patients were randomly allocated to RT group and Control group. RT group received AO-90 amino acid solution, while Control group infused Amiparen (commercial methionine and cysteine containing amino acid solution) as protein source for 14 days' TPN with 5-FU and mitomycin C (MMC). The over all clinical response rate (PR+CR) in RT and Control groups were 26.3% and 8.1%, respectively, with significant statistical difference in both values at p = 0.015. Fourteen advanced gastric cancer patients allocated to RT and Control group randomly and received each amino acid as protein source for 7 days TPN with 5-FU administration. All cases were performed gastrectomy without waiting period, and resected material was examined the histological response. In the 7 cases of RT group, grade 2 was seen in 4 cases, grade 1-b in 1, grade 1-a in 1 and grade 0 in 1. In the 7 of Control, 3 cases were grade 1-a and the remaining 4 were grade 0. There were significant differences in both degree and incidence of the histological response at p = 0.016. A stage IV gastric cancer patient with marked liver metastasis received 2 times RT therapy with 5-FU and MMC for 14 days and undertaken gastrectomy after 22 day, waiting period. Resected gastric cancer showed grade 2 to 3 histological response, and the liver metastasis showed marked effect as PR to CR.

[Multitherapy of advanced esophageal carcinoma with special reference to pre- and post-operative administration of cis-platinum].

We discussed the results of multitherapy after pre- and post-operative administration of cis-platinum (CDDP) in resected cases of advanced esophageal carcinoma. The patients were, pre-operatively, dosed in the following ways; 1) CDDP (50 mg, 1/week) X 2-3, 2) CDDP (50 mg, 1-week) +BLM (15 mg, 1/week) X 2-3 or +MTX (30mg, 1/week) X 2-3. The patients under went surgery 1 to 2 weeks later. Post-operative administration of CDDP + MTX, or CDDP + BLM was performed 3-4 times about 3 weeks after surgery. Intra-operative and/or post-operative irradiation was also performed. CDDP was administered pre-operatively in 11 cases who ranged in age 45 to 71. Regarding stage, 2 were stIII and 9 were stIV; and curabilities where cIII in 2 cases, c I in 5 and c 0 in 4. With regard to surgery, the right thoracic and abdominal approach was adopted in 7 cases and the left thoracic and abdominal approach adopted in 3. Blunt dissection was performed in 1 case. We have never experienced post-operative complication of histological effects noticed in resected specimens, Ef1 was evaluated in 3/11 and Ef2 was noticed in 2/11. Patients who achieved an Ef2-1 effect due to the administration of CDDP as part of the multitherapy made satisfactory progress. On the other hand, patients who did not react to CDDP and who had marked vascular invasion died after a short period.

[Basal plasma cholecystokinin levels in digestive diseases--comparison between CCK-8 like bioactivity by bioassay and CCK immunoreactivity by radioimmunoassay].

Basal plasma cholecystokinin levels were measured by a bioassay using dispersed rat pancreatic acini in various digestive diseases and compared with corresponding values by CCK-8 specific radioimmunoassay. The mean basal level in healthy volunteers was 0.40 +/- 0.06 pM. The basal level in liver cirrhosis was significantly elevated to 0.92 +/- 0.14 pM. The patients with cholestasis, that is, primary biliary cirrhosis and obstructive jaundice due to choledocholithiasis, bile duct cancer or lymph node metastasis , had markedly increased basal plasma CCK-8 like bioactivities from 1.88 pM to more than 25 pM. These CCK bioactivities were not correlative with CCK immunoreactivities. It was concluded not only that basal plasma CCK in patients with bile flow disturbance were truly increased, but also that interfering substances of the bioassay might appear in the plasma of these patients.

[Postoperative nutritional assessment in gastric and colorectal cancer].

From the 200 malnutritional cancer patients, we had obtained, so called, prognostic nutritional index (PNI): PNI = 10 X Alb. + 0.005 Lymph. C., where Alb. is serum albumin level (g/dl) and Lymph. C. is total lymphocytes count of peripheral blood level. This index, as we had reported, shows linear predictive model correlating the risk of operative complication, mortality or both with nutritional status. In this study, we report on the utility of the PNI as a nutritional index (NI) for postoperative patients. The subjects of this study were 22 gastric cancer patients (G group), performed total gastrectomy or proximal gastrectomy, and 18 colorectal cancer patients (C group), underwent colectomy or rectal resection and anastomosis but amputation. All these cases underwent nutritional support by TPN postoperatively. The values of NI of both groups were the lowest at the first postoperative day, and increased gradually to the seventh postoperative day. And the value of C group was higher than that of G group throughout the TPN period: From the first postoperative day to the 14th day. These results reflected the result obtained from the estimation of nitrogen balance, urinary 3-methylhistidine excretion and serum rapid turnover protein (transferrin, prealbumin and retinol binding protein). These results suggest that the NI is useful to estimate the improvement of the postoperative nutritional status.

[Prognostic nutritional index in gastrointestinal surgery of malnourished cancer patients].

Based on assessment of 200 malnourished cancer patients of digestive organs, a multiparameter index of nutritional status was defined to relating the risk of postoperative complications to base line nutritional status. The linear predictive model relating the risk of operative complication, mortality or both to nutritional status is given by the relation: prognostic nutritional index (PNI) = 10 Alb. + 0.005 Lymph. C., where Alb. is serum albumin level (g/100 ml) and Lymph. C. is total lymphocytes count/mm3 peripheral blood. When applied prospectively to 189 gastrointestinal surgical patients those who were malnourished and treated by TPN preoperatively, this index provided an accurate, quantitative estimate of operative risk. In general, resection and anastomosis of gastrointestinal tract can be safely practiced when the index is over 45. The same procedure may be dangerous between 45 and 40. In below 40, this kind of operation may be contraindicated. The prognostic nutritional index is useful also to know the prognosis of patients with terminal cancer. Despite practicing TPN to cancer patients with near terminal stages, if the PNI remains below 40 and total lymphocytes count remains below 1,000/mm3, the patients has high possibility to die within the next two months.

[Postoperative changes in immunoreactive plasma endothelin concentrations].

We investigated postoperative changes in immunoreactive plasma endothelin (ET-1) concentrations using a highly specific and sensitive radioimmunoassay developed for this purpose. The patients were divided into two groups: 10 patients underwent subtotal-esophagectomy by combined right thoracotomy and celiotomy (EC-group), and an other 10 underwent total gastrectomy via celiotomy only (GC-group). Before operation, plasma ET concentrations in both groups were within the normal range. After operation, the mean plasma ET-1 concentration in the EC group was significantly higher than the preoperative concentration (p less than 0.01). But in the GC-group, there were no significant change. A significant correlation existed between the change in plasma ET-1 concentration and the amount of intraoperative hemorrhage (p less than 0.05). Additionally in the EC group, a significant correlation existed between plasma ET-1 concentrations after operation and the change in the atrial-natriuretic-peptide (ANP) concentration during operation (p less than 0.05). There was no correlation between ET-1 concentrations and blood pressure. We believe that the increase in the ET-1 concentration was attributable to endothelial cell injury and may increase ANP secretion. We speculate that the plasma ET-1 concentration may be a reliable index of surgical stress.