Direct peroral cholangioscopy with red dichromatic imaging 3 detected the perihilar margin of superficial papillary extension in a patient with intraductal papillary neoplasm of the bile duct.

Intraductal papillary neoplasms of the bile duct (IPNB) are a tumor derived from bile duct epithelium that tends to spread laterally and non-invasively. Surgery is the first-choice treatment for IPNB. It is extremely important to accurately diagnose the extent of lateral tumor extension. Although peroral cholangioscopy (POCS) is a potentially useful modality for detecting tumor range with direct observation, poor image quality is a limitation of POCS. Recently, a new-generation endoscopy system (EVIS X1) was equipped with functions such as red dichromatic imaging to improve image quality. A 75-year-old man with cholangitis was referred to our department. Various imaging studies showed a mass in the middle to lower bile duct and dilatation of the common bile duct and the intrahepatic bile duct. Endoscopic retrograde cholangiopancreatography was performed. A biopsy of the main tumor in the lower common bile duct revealed IPNB. It was difficult to determine the extent of superficial tumor extension with modalities such as contrast-enhanced computed tomography, magnetic resonance imaging, and endoscopic ultrasonography but the detailed evaluation was possible using POCS with red dichromatic imaging 3. The patient underwent hepatopancreatoduodenectomy. This case suggests the usefulness of direct observation using POCS with red dichromatic imaging 3 to determine the range of IPNB.

Tumor necrosis factor­related apoptosis­inducing ligand is a novel transcriptional target of runt­related transcription factor 1.

Runt­related transcription factor 1 (RUNX1), which is also known as acute myeloid leukemia 1 (AML1), has been frequently found with genomic aberrations in human leukemia. RUNX1 encodes a transcription factor that can regulate the expression of hematopoietic genes. In addition, tumor necrosis factor­related apoptosis­inducing ligand (TRAIL) performs an important function for malignant tumors in immune surveillance. However, the regulatory mechanism of TRAIL expression remain to be fully elucidated. In the present study, tetradecanoylphorbol 13­acetate­treated megakaryocytic differentiated K562 cells was used to examine the effect of RUNX1 on TRAIL expression. Luciferase assay series of TRAIL promoters for the cells co­transfected with RUNX1 and core­binding factor ß (CBFß) expression vectors were performed to evaluate the nature of TRAIL transcriptional regulation. Electrophoresis mobility shift assay of the RUNX1 consensus sequence of the TRAIL promoter with recombinant RUNX1 and CBFß proteins was also performed. BloodSpot database analysis for TRAIL expression in patients with acute myeloid leukemia were performed. The expression of TRAIL, its receptor Death receptor 4 and 5 and RUNX1 in K562 cells transfected with the RUNX1 expression vector and RUNX1 siRNA were evaluated by reverse transcription­quantitative PCR (RT­qPCR). TRAIL and RUNX1­ETO expression was also measured in Kasumi­1 cells transfected with RUNX1­ETO siRNA and in KG­1 cells transfected with RUNX1­ETO expression plasmid, both by RT­qPCR. Cell counting, lactate dehydrogenase assay and cell cycle analysis by flow cytometry were performed on Kasumi­1, KG­1, SKNO­1 and K562 cells treated with TRAIL and HDAC inhibitors sodium butyrate or valproic acid. The present study demonstrated that RUNX1 is a transcriptional regulator of TRAIL. It was initially found that the induction of TRAIL expression following the megakaryocytic differentiation of human leukemia cells was RUNX1­dependent. Subsequently, overexpression of RUNX1 was found to increase TRAIL mRNA expression by activating its promoter activity. Additional analyses revealed that RUNX1 regulated the expression of TRAIL in an indirect manner, because RUNX1 retained its ability to activate this promoter following the mutation of all possible RUNX1 consensus sites. Furthermore, TRAIL expression was reduced in leukemia cells carrying the t(8;21) translocation, where the RUNX1­ETO chimeric protein interfere with normal RUNX1 function. Exogenous treatment of recombinant TRAIL proteins was found to induce leukemia cell death. To conclude, the present study provided a novel mechanism, whereby TRAIL is a target gene of RUNX1 and TRAIL expression was inhibited by RUNX1­ETO. These results suggest that TRAIL is a promising agent for the clinical treatment of t(8;21) AML.

C11orf21, a novel RUNX1 target gene, is down-regulated by RUNX1-ETO.

The fusion protein RUNX1-ETO is an oncogenic transcription factor generated by t(8;21) chromosome translocation, which is found in FAB-M2-type acute myeloid leukemia (AML). RUNX1-ETO is known to dysregulate the normal RUNX1 transcriptional network, which should involve essential factors for the onset of AML with t(8;21). In this study, we screened for possible transcriptional targets of RUNX1 by reanalysis of public data in silico, and identified C11orf21 as a novel RUNX1 target gene because its expression was down-regulated in the presence of RUNX1-ETO. The expression level of C11orf21 was low in AML patient samples with t(8;21) and in Kasumi-1 cells, which carry RUNX1-ETO. Knockdown of RUNX1-ETO in Kasumi-1 cells restored C11orf21 expression, whereas overexpression of RUNX1 up-regulated C11orf21 expression. In addition, knockdown of RUNX1 in other human leukemia cells without RUNX-ETO, such as K562, led to a decrease in C11orf21 expression. Of note, the C11orf21 promoter sequence contains a consensus sequence for RUNX1 binding and it was activated by exogenously expressed RUNX1 based on our luciferase reporter assay. This luciferase signal was trans-dominantly suppressed by RUNX1-ETO and site-directed mutagenesis of the consensus site abrogated the reporter activity. This study demonstrated that C11orf21 is a novel transcriptional target of RUNX1 and RUNX1-ETO suppressed C11orf21 transcription in t(8;21) AML. Thus, through this in silico approach, we identified a novel transcriptional target of RUNX1, and the depletion of C11orf21, the target gene, may be associated with the onset of t(8;21) AML.

Biliary Schwannoma That Required Differentiation from Bile Duct Cancer.

Schwannomas are benign tumors originating from Schwann cells, which are the main component of the neural sheath. Biliary schwannomas are extremely rare. We report the case of a 78-year-old man who presented with no abdominal symptoms or jaundice. CT imaging showed a hyperdense mass extending along the extrahepatic bile duct, and the upstream bile ducts were dilated. We performed extrahepatic bile duct resection under a preoperative diagnosis of the extrahepatic bile duct cancer. A histopathological examination of the resected specimen revealed that the tumor consisted of spindle cells which exhibited a palisading arrangement. Immunohistochemical staining was positive for protein S-100 and vimentin. Based on these pathological findings, we diagnosed the patient with schwannoma of the extrahepatic bile duct. Our search of the relevant literature revealed 19 case studies of biliary schwannomas. In our case, the surgical findings showed that the tumor was noninvasive and mobile. During surgery, a fast frozen section analysis was performed, and no malignant findings were observed. These results enabled us to avoid extrahepatic bile duct resection with major hepatectomy. We experienced a case of biliary schwannoma that was difficult to distinguish from bile duct cancer.

[Laparoscopic Lymphadenectomy without Gastrectomy for Lymph Nodes Recurrence after Endoscopic Submucosal Dissection (ESD)].

A case oflaparoscopic lymphadenectomy in a patient with lymph node recurrence after endoscopic submucosal dissection (ESD)is presented. A 77-year-old man underwent ESD for gastric cancer. After 2 years, the patient was referred to our hospital with the diagnosis of lymph node recurrence. We offered radical surgery, including gastrectomy and lymphadenectomy; however, this suggestion was denied by the patient because ofstrong anxiety for gastrectomy. As an alternative therapy, laparoscopic lymphadenectomy for the limited area of high recurrence, without gastrectomy, was performed. Postoperative course was uneventful. The patient was discharged on the 10th postoperative day and remains cancer-free over 2 years after the operation. Laparoscopic lymphadenectomy for high risk area of recurrence may be considered in frail elderly patients to avoid the high burden ofgastrectomy.

[A Case of Curatively Resected Goblet Cell Carcinoid of the Appendix Diagnosed via Intraoperative Frozen Sectional Examination].

A 52-year-old patient presented with epigastric pain.An enhanced CT scan showed a strongly enhanced appendix with abscess formation.Appendectomy was performed under the diagnosis of acute appendicitis with perityphlitic abscess.The stump of the appendix was white and hard, suggesting malignant transformation.Intraoperative frozen sectional examination indicated goblet cell carcinoid(GCC)of the appendix.Thereafter, we performed ileocecal resection with lymphadenectomy (D3).The final pathological diagnosis was GCC, pSS, pN1, Stage III a by the Japanese classification of colorectal carcinoma. Immunohistochemical examination was consistent with GCC including synaptophysin(+), chromogranin A(+), somatostatin receptor(SSTR)2(±), SSTR5(+), and cytokeratin 20(+).The patient received adjuvant chemotherapy and remains cancer-free over 5 years after the operation.

[Simultaneous Laparoscopic Resection of Gastric Cancer and Hepatocellular Carcinoma].

A report of simultaneous laparoscopic resection for a patient with synchronous gastric cancer and hepatocellular carcinoma (HCC)is presented.A 76-year-old man was referred to our hospital for gastric cancer located in the antrum.In the preoperative examination, enhanced CT and MRI revealed a liver tumor located at S2 that had high contrast enhancement in the arterial phase but that was not washed out in the delayed phase.An early HCC was suspected, and simultaneous laparoscopic distal gastrectomy and partial resection of the liver was performed.The postoperative course was uneventful, and the patient was discharged on the 14th postoperative day.Simultaneous laparoscopic resection of gastric cancer and HCC is possible with special attention to surgical procedures and port settings.

[A Case of Advanced Gastric Cancer with Extensive Lymph Node Metastases Treated by Capecitabine plus Cisplatin plus Trastuzumab Chemotherapy,Followed by Conversion Surgery].

An 82-year-old woman underwent upper gastrointestinal endoscopy to evaluate upper abdominal pain.A type 2 tumor (adenocarcinoma, por, HER2+)was found in the lesser curvature of the gastric antrum.Abdominal CT showed bulky lymph node metastases and pancreatic invasion of lymph node No.6 , resulting in a diagnosis of cT3N3M0, Stage III B.Radical resection was not possible by gastrectomy, and chemotherapy(capecitabine plus cisplatin plus trastuzumab)was administered. The primary lesion and lymph node showed significant regression on CT after the administration of 8 courses of chemotherapy, which also clarified the border between the lymph node and pancreas.At this stage, it was determined that radical resection was feasible; distal gastrectomy(Roux-en-Y reconstruction)and D2 dissection and cholecystectomy were performed.No cancer cells were found in the primary lesion on histopathology.The therapeutic effect of preoperative chemotherapy was assessed as Grade 3, pCR, and retained tumor was only found in lymph node No.5 . On follow-up observation, the patient is alive 11 months after surgery, with no evidence of recurrence without neoadjuvant chemotherapy.

[Synchronous Triple Malignant Tumors (Hilar Cholangiocarcinoma, Ascending Colon Cancer, Liposarcoma) Resected in a Two-Stage Procedure--A Case Report].

A 70-year-old man with a history of myocardial infarction (MI) and taking 2 antiplatelet drugs was diagnosed with anemia his 6-month post-MI checkup. A lower gastrointestinal endoscopy detected ascending colon cancer, and contrast-enhanced a computed tomography scan revealed hilar cholangiocarcinoma as well as lesions suspicious for gastrointestinal stromal tumors of the small intestine. The patient was given a preoperative diagnosis of synchronous triple malignant tumors. The decision to perform a two-stage procedure was made for the following reasons: the impossibility of discontinuing antiplatelet drugs 6 months after drug-eluting stent placement, continuous bleeding due to colon cancer and the possibility of suffering severe stress from surgery while at high risk for diseases such as hepatic failure. In the initial procedure, a right hemicolectomy and surgical resection of the mesenteric tumor (later diagnosed as a liposarcoma) were performed after portal vein embolization. Confirmation of an enlarged residual liver was confirmed 2 months after the initial procedure. The patient underwent right hepatectomy and resection of the extrahepatic bile duct and the biliary tract was surgically reconstructed. Safe resection of tumors was successfully performed by choosing a two-stage procedure for triple malignancy, including hilar cholangiocarcinoma, ascending colon cancer, and liposarcoma, in a single patient.

[A Case of Advanced Gastric Cancer for Which Curative Resection Was Performed, Despite CEA Elevation].

A 32-year-old man was admitted to our hospital with the complaint of epigastric pain. Gastrointestinal endoscopy revealed a type 5 advanced gastric cancer at the posterior wall of the antrum. Contrast-enhanced computed tomography (CT) and endoscopic ultrasonography showed a fluid collection, indicating peritoneal metastasis. CEA levels were elevated, at 16.5 ng/mL. A diagnosis was made of cStage Ⅳ (T4aN3H0P1M1), and he underwent first-line chemotherapy using CDDP and S-1. However, this immediately failed with the severe adverse effect of vomiting.Docetaxel and S-1 were adopted as second-line chemotherapy. Since progression of the disease was confirmed after 8 cycles of second-line chemotherapy, nab-paclitaxel was administered as third-line chemotherapy. Despite a trend of increasing CEA after 4 cycles of third-line chemotherapy, CT revealed a tumor volume reduction as well as the disappearance of the fluid collection, after which staging laparoscopy was performed. Based on the finding that non-curative factors such as fluid collection and peritoneal nodules were not observed, distal gastrectomy was performed. Histopathological examination showed a ypStage ⅠA (T1bN0H0P0M0)tumor with a grade 3 therapeutic response to chemotherapy.The patient is currently doing well with no recurrence 11 months after the operation.

[A Case of Pathological Complete Response after Primary Tumor Resection Followed by Hepatectomy-A Sigmoid Colon Cancer with Synchronous Liver Metastases].

The case is of a 62-year-old man with no medical history and no family history.A type 2 tumor was found in the entire circumference of the sigmoid colon by colonoscopy after a positive result on a fecal occult blood test, and 5 liver metastases were recognized in both lobes of the liver by using contrast-enhanced CT.He was first treated by primary tumor resection. Subsequently, 5-fluorouracil/l-leucovorin/oxaliplatin (mFOLFOX6) plus bevacizumab (BV) was started 1 month after the surgery and a total of 8 cycles of mFOLFOX6 plus BV were administered without any adverse events.On CT assessment after the chemotherapy, the patient was diagnosed with stable disease according to RECIST guidelines since the size of the tumor only showed a slight reduction.However, it was considered to be an optimal response based on the morphologic criteria. Thereafter, a medial segmentectomy and partial resection of the liver was performed.A mucus reservoir was found in the tumor site, and no viable tumor cells were detected pathologically, which confirmed the pathological complete response with mFOLFOX6 plus BV.

Phenotypic spectrum of COL4A1 mutations: porencephaly to schizencephaly.

OBJECTIVE: Recently, COL4A1 mutations have been reported in porencephaly and other cerebral vascular diseases, often associated with ocular, renal, and muscular features. In this study, we aimed to clarify the phenotypic spectrum and incidence of COL4A1 mutations. METHODS: We screened for COL4A1 mutations in 61 patients with porencephaly and 10 patients with schizencephaly, which may be similarly caused by disturbed vascular supply leading to cerebral degeneration, but can be distinguished depending on time of insult. RESULTS: COL4A1 mutations were identified in 15 patients (21%, 10 mutations in porencephaly and 5 mutations in schizencephaly), who showed a variety of associated findings, including intracranial calcification, focal cortical dysplasia, pontocerebellar atrophy, ocular abnormalities, myopathy, elevated serum creatine kinase levels, and hemolytic anemia. Mutations include 10 missense, a nonsense, a frameshift, and 3 splice site mutations. Five mutations were confirmed as de novo events. One mutation was cosegregated with familial porencephaly, and 2 mutations were inherited from asymptomatic parents. Aberrant splicing was demonstrated by reverse transcriptase polymerase chain reaction analyses in 2 patients with splice site mutations. INTERPRETATION: Our study first confirmed that COL4A1 mutations are associated with schizencephaly and hemolytic anemia. Based on the finding that COL4A1 mutations were frequent in patients with porencephaly and schizencephaly, genetic testing for COL4A1 should be considered for children with these conditions.

Regulation of vasopressin gene expression by cAMP and glucocorticoids in parvocellular neurons of the paraventricular nucleus in rat hypothalamic organotypic cultures.

Arginine vasopressin (AVP) in the parvocellular neurons of the paraventricular nucleus (PVN) is known to play an important role in the hypothalamo-pituitary-adrenal axis. In the present study, we examined how cAMP and glucocorticoids regulate AVP gene expression in the parvocellular neurons of the PVN in rat hypothalamic organotypic cultures with in situ hybridization. AVP heteronuclear (hn) RNA, an indicator for gene transcription, was induced in the PVN with incubation of forskolin as reported previously, and AVP mRNA was increased by forskolin in the presence of the gene transcription inhibitor 5,6-dichloro-1-D-ribofuranosylbenzimidazole (DRB). These data indicate that cAMP could increase not only gene transcription but also mRNA stability. Dexamethasone treatment, in contrast, significantly decreased AVP mRNA expression levels in the PVN, but this inhibitory action was abolished in the presence of DRB or the sodium channel blocker tetrodotoxin (TTX). However, when the hypothalamic slices were treated with forskolin, dexamethasone decreased AVP mRNA expression even in the presence of DRB and/or TTX. Furthermore, AVP hnRNA expression induced by forskolin was attenuated by dexamethasone treatment in the presence of TTX. These data indicate that dexamethasone could act on AVP cells independently of action potentials to decrease mRNA stability and to suppress AVP gene transcription during stimulation by cAMP. Thus, it was demonstrated that: (1) cAMP upregulates AVP gene transcriptionally and post-transcriptionally, (2) the mode of action of glucocorticoids was dependent on whether the cells were stimulated by cAMP, and (3) the interactions between cAMP and glucocorticoids encompass both gene transcription and mRNA stability.

Inhibition of heme oxygenase ameliorates sepsis-induced liver dysfunction in rats.

PURPOSE: The disintegration of heme produces carbon monoxide (CO), a known vasodilator, which is catalyzed by heme oxygenase (HO). This study aimed to clarify the effect of HO inhibition on septic rat livers using two types of HO inhibitors; Sn-protoporphyrin (Sn-PP) and Zn-protoporphyrin (Zn-PP). METHODS: Sepsis was induced in male Sprague-Dawley rats by cecal ligation and puncture (CLP). Either NaOH or HO inhibitors were injected intraperitoneally; first 18 h prior to CLP, then immediately after CLP. The animals were killed 12 and 24 h after CLP and the liver tissue and plasma were harvested. RESULTS: Using Northern blotting, we found that mRNA of the stress-inducible isozyme, HO-1, was dramatically induced 12 h after CLP. Administering the HO inhibitors, Sn-PP and Zn-PP (5 micromol/kg), induced a significant inhibition of the elevation of aspartate aminotransferase plasma levels, the elevation of cyclic guanosine monophosphete (cGMP) in the liver tissue, and the increase in the sinusoidal space ratio, 24 h after CLP. Both Sn-PP and Zn-PP decreased the mortality rate 24 h after CLP compared with normal saline. CONCLUSIONS: CO produced by excessively induced HO-1 after CLP promotes an immoderate dilation of the sinusoidal space through the up-regulation of cGMP, resulting in liver dysfunction. Therefore, administering HO inhibitors at appropriate doses could be beneficial for the amelioration of sepsis-induced liver dysfunction.