The transcription factor STAT5 is critical in dendritic cells for the development of TH2 but not TH1 responses.

Dendritic cells (DCs) are critical in immune responses, linking innate and adaptive immunity. We found here that DC-specific deletion of the transcription factor STAT5 was not critical for development but was required for T helper type 2 (TH2), but not TH1, allergic responses in both the skin and lungs. Loss of STAT5 in DCs led to the inability to respond to thymic stromal lymphopoietin (TSLP). STAT5 was required for TSLP-dependent DC activation, including upregulation of the expression of costimulatory molecules and chemokine production. Furthermore, TH2 responses in mice with DC-specific loss of STAT5 resembled those seen in mice deficient in the receptor for TSLP. Our results show that the TSLP-STAT5 axis in DCs is a critical component for the promotion of type 2 immunity at barrier surfaces.

Critical Role of TSLP Receptor on CD4 T Cells for Exacerbation of Skin Inflammation.

Thymic stromal lymphopoietin (TSLP) is a key cytokine that initiates and promotes allergic inflammation both in humans and mice. It is well known that TSLP is important in initial step of inflammation by stimulating dendritic cells to promote Th2 differentiation of naive T cells. However, TSLP is abundantly produced in the late phase of inflammation, as well; therefore, we focused on the function of TSLP in chronic Th2-type inflammation. By establishing a novel (to our knowledge) chronic allergic skin inflammation mouse model with repetitive challenges of hapten after sensitization, we demonstrated that CD4 T cell-specific deletion of TSLP receptor (TSLPR) resulted in near-complete ablation of ear swelling and infiltration of CD4 T cells and eosinophils, but after second challenge. Of note, TSLPR deletion on CD4 T cells did not affect acute inflammation. As expected, transfer of Ag-sensitized wild-type CD4T cells, but not of TSLPR-deficient CD4T cells, increased skin inflammation in the model upon challenge. Furthermore, production of IL-4 from TSLPR-deficient CD4T cells in inflamed ear lesions was markedly diminished, demonstrating that TSLP-dependent IL-4 production from CD4T cells was critical for the exacerbation of skin inflammation. Similar results were obtained in Th2-type allergic skin inflammation model using MC903. Collectively, these results indicate that TSLP acts directly on CD4 T cells to elicit pathogenesis of Th2 cells, thereby having a critical role in exacerbation of skin inflammation in the chronic phase.

Cutting Edge: Nqo1 Regulates Irritant Contact Hypersensitivity against Croton Oil through Maintenance of Dendritic Epidermal T Cells.

Irritant contact dermatitis (ICD) is associated with local release of inflammatory mediators such as reactive oxygen species and regulated by various antioxidative enzymes and antioxidants. Although Nqo1 is involved in antioxidative reactions and detoxification, its role in ICD remains unknown. Nqo1-deficient mice exhibited augmented ear swelling accompanied by neutrophil infiltration in the croton oil-induced mouse ICD model. In the skin of Nqo1-deficient mice, Vγ5Vδ1+ dendritic epidermal T cells (DETCs), which are known to suppress ICD, were severely reduced. As the transfer of DETCs into Nqo1-deficient mice reversed an increased ICD response, loss of DETCs could account for the increased ICD. DETCs from Nqo1-deficient mice were sensitive to oxidative stress-induced cell death in vitro, and antioxidant NAC treatment in the ears of these mice rescued the number of DETCs and produced a normal ICD response. Taken together, the current results demonstrate that antioxidative enzyme Nqo1 regulates ICD through DETC maintenance.

Rasal3-mediated T cell survival is essential for inflammatory responses.

Fine regulation of the Ras/mitogen-activating protein kinase (MAPK) pathway is crucial in controlling the survival, proliferation, and development of various types of cells. Ras-activating protein-like 3 (Rasal3) is a T cell-specific Ras GTPase-activating protein that negatively regulates T cell receptor (TCR)-induced activation of Ras/MAPK pathway. Rasal3-deficient mice showed a decreased number of naive T cells because Rasal3 is required for the survival of naive T cells. In the current study, we observed ameliorated Type1 T helper (Th1) cell- and Type2 T helper (Th2) cell-dependent contact hypersensitivity reactions in Rasal3-deficient mice, along with a marked shortage of T cells at regional lymph node. Activated Rasal3-deficient T cells showed an increased cell death with reduced Bcl2 expression, suggesting that Rasal3 is required for the survival of not only naïve T cells but also activated T cells. Collectively, Rasal3 controls the magnitude of inflammatory responses through the survival of both naive T cells and activated T cells in vivo.

A Histone Methyltransferase ESET Is Critical for T Cell Development.

ESET/SETDB1, one of the major histone methyltransferases, catalyzes histone 3 lysine 9 (H3K9) trimethylation. ESET is critical for suppressing expression of retroviral elements in embryonic stem cells; however, its role in the immune system is not known. We found that thymocyte-specific deletion of ESET caused impaired T cell development, with CD8 lineage cells being most severely affected. Increased apoptosis of CD8 single-positive cells was observed, and TCR-induced ERK activation was severely inhibited in ESET(-/-) thymocytes. Genome-wide comprehensive analysis of mRNA expression and H3K9 trimethylation revealed that ESET regulates expression of numerous genes in thymocytes. Among them, FcγRIIB, whose signaling can inhibit ERK activation, was strongly and ectopically expressed in ESET(-/-) thymocytes. Indeed, genetic depletion of FcγRIIB in ESET(-/-) thymocytes rescued impaired ERK activation and partially restored defective positive selection in ESET(-/-) mice. Therefore, impaired T cell development in ESET(-/-) mice is partly due to the aberrant expression of FcγRIIB. Collectively, to our knowledge, we identify ESET as the first trimethylated H3K9 histone methyltransferase playing a crucial role in T cell development.

Cutting edge: identification of the thymic stromal lymphopoietin-responsive dendritic cell subset critical for initiation of type 2 contact hypersensitivity.

The cytokine thymic stromal lymphopoietin (TSLP) has been implicated in the initiation and progression of allergic inflammation through its ability to activate dendritic cells (DCs). However, the identity of the DC subset that responds to TSLP is not known. In this study we use a CCL17 reporter strain to identify the TSLP-responsive DC subset. In vitro, TSLP induced CD11b(high) DCs to express CCL17, to increase CCR7-mediated migration activity, and to drive Th2 differentiation of naive CD4 T cells. In vivo, following skin sensitization, we found that a subset of Ag-bearing CCL17(+)CD11b(high) migratory DCs, but not Ag-bearing CCL17(-) migratory DCs, in skin lymph nodes were capable of driving Th2 differentiation and were dramatically reduced in TSLPR-deficient mice. Taken together, these results demonstrate that TSLP activated a subset of CD11b(+) DCs in the skin to produce CCL17, upregulate CCR7, and migrate to the draining lymph node to initiate Th2 differentiation.

Epithelial cell-derived cytokine TSLP activates regulatory T cells by enhancing fatty acid uptake.

Epithelial cells control a variety of immune cells by secreting cytokines to maintain tissue homeostasis on mucosal surfaces. Regulatory T (Treg) cells are essential for immune homeostasis and for preventing tissue inflammation; however, the precise molecular mechanisms by which epithelial cell-derived cytokines function on Treg cells in the epithelial tissues are not well understood. Here, we show that peripheral Treg cells preferentially respond to thymic stromal lymphoprotein (TSLP). Although TSLP does not affect thymic Treg differentiation, TSLP receptor-deficient induced Treg cells derived from naïve CD4+ T cells are less activated in an adoptive transfer model of colitis. Mechanistically, TSLP activates induced Treg cells partially through mTORC1 activation and fatty acid uptake. Thus, TSLP modulates the activation status of induced Treg through the enhanced uptake of fatty acids to maintain homeostasis in the large intestine.

TSLP enhances the function of helper type 2 cells.

The cytokine thymic stromal lymphopoietin (TSLP) has been implicated in the development and progression of allergic inflammation in both humans and mice. TSLP has been shown to promote a Th2-type response through upregulation of OX40L on dendritic cells, and through direct induction of IL-4 production in naïve CD4+ T cells. However, its direct effect on effector Th cells has not been extensively investigated. In this study, we show that the level of TSLP receptor (TSLPR) expression on mouse effector Th2 cells is higher than on Th1 and Th17 cells, and that TSLP induced proliferation of effector Th2, but not Th1 nor Th17 cells. TSLP also induced the phosphorylation of signal transducer and activator of transcription (Stat) 5, and expression of the anti-apoptotic factor Bcl-2 in Th2 cells. Finally, TSLP-mediated proliferation on Th2 cells was enhanced by TCR stimulation, through IL-4-mediated induction of TSLPR expression. Taken together, these results indicate that TSLP is involved in exacerbation of mouse Th2-mediated allergic inflammation in a Th2 environment through direct stimulation of Th2 effector cells.

Repressor of GATA negatively regulates murine contact hypersensitivity through the inhibition of type-2 allergic responses.

Repressor of GATA (ROG) inhibits Th2 cell differentiation and allergic airway inflammation in the lung. To determine the role of ROG in the pathogenesis of contact hypersensitivity (CHS), a hapten-induced mouse model of CHS using ROG Tg and ROG-deficient (ROG(-/-)) was used. ROG Tg mice showed little ear swelling, while ROG(-/-) mice showed enhanced ear swelling in comparison to wild type mice. Interstitial edema and mast cell degranulation at the local inflammation sites were mild in ROG Tg mice and exacerbated in ROG(-/-) mice. In addition, the serum total IgE and hapten-specific IgG1 levels were increased in ROG(-/-) mice. Adoptive transfer of ROG(-/-) CD4(+) T cells exacerbated CHS in wild type mice, while transfer of ROG Tg CD4(+) T cells resulted in the attenuation of CHS. These results indicate ROG negatively regulates the induction of CHS by controlling the CD4(+) T cell-mediated allergic responses, including IgE generation and mast cell degranulation.

Enhanced Th2 cell differentiation and allergen-induced airway inflammation in Zfp35-deficient mice.

Studies of human asthma and of animal models of allergic airway inflammation revealed a crucial role for Th2 cells in the pathogenesis of allergic asthma. Kruppel-type zinc finger proteins are the largest family of a regulatory transcription factor for cellular development and function. Zinc finger protein (Zfp) 35 is an 18-zinc finger motif-containing Kruppel-type zinc finger protein, while its function remains largely unknown. The aim of this study was to clarify the role of Zfp35 in the pathogenesis of Th2-dependent allergic inflammation, such as allergic asthma. We examined airway eosinophilic inflammation and hyperresponsiveness in two mouse models, which use our newly generated Zfp35-deficient (Zfp35(-/-)) mice and adoptive transfer of cells. In Zfp35(-/-) mice, Th2 cell differentiation, Th2 cytokine production, eosinophilic inflammation, and airway hyperresponsiveness were substantially enhanced. Furthermore, adoptive transfer of Ag-sensitized Zfp35(-/-) CD4 T cells into the asthmatic mice resulted in enhanced airway inflammation and airway hyperresponsiveness. These results indicate that Zfp35 controls Th2 cell differentiation, allergic airway inflammation, and airway hyperresponsiveness in a negative manner. Thus, Zfp35 may control Th2-dependent diseases, such as allergic asthma.

Baculovirus activates murine dendritic cells and induces non-specific NK cell and T cell immune responses.

We previously reported that the baculovirus induced a strong host immune response against infections and malignancies. Among the immune cells, the dendritic cells were most strongly infected and activated by the baculovirus, although the exact mechanism remained unclear. Here, we evaluated the non-specific immune responses of bone marrow-derived dendritic cells (BMDCs) after infection by a wild-type baculovirus. MHC class I and II molecules and co-stimulation molecules (CD40, CD80, and CD86) on BMDCs were up-regulated by baculovirus infection. At the same time, the BMDCs produced pre-inflammatory cytokines (IL-6, IL12p70, and TNF-alpha) and IFN-alpha. NK cells showed IFN-gamma production, CD69 up-regulation, and enhanced cytotoxicity when they were co-cultured with baculovirus-infected BMDCs. T cells showed IFN-gamma production, CD69 up-regulation, and cell proliferation. Ex vivo analysis performed in vitro produced similar results. These findings suggested that baculovirus-infected dendritic cells induce non-specific immune responses and can be used as an immunotherapeutic agent against viral infections and malignancies, together with present therapeutic drug regimens.

Oncocytic adrenocortical carcinoma.

Only 17 cases of oncocytic adrenocortical carcinoma have been reported in the English literature. Here, we report an incidental case of oncocytic adrenocortical carcinoma. The patient was a 69-year-old man with the chief complaint of abdominal pain. Abdominal computed tomography revealed a left adrenal tumor. No hormonal symptoms were observed. The excised tumor was whitish, encapsulated, and 75 x 60 x 45 mm in size. Large polygonal tumor cells were arranged in a generally diffuse architecture and exhibited abundant eosinophilic granular cytoplasm. Nuclear atypia with atypical mitotic figures and capsular and sinusoidal invasions were observed. The tumor cells were immunopositive for vimentin, neuron-specific enolase, and synaptophysin but not for alpha-inhibin, melan A, or p53. Diffuse and strong immunopositivity with an antimitochondrial antibody proved that this tumor was truly oncocytic. Upon review of previous cases of oncocytic adrenocortical tumors, we reconsidered the diagnostic findings of the potential for malignancy.

Induction of natural killer cell-dependent antitumor immunity by the Autographa californica multiple nuclear polyhedrosis virus.

Wild-type Autographa californica multiple nuclear polyhedrosis virus (AcMNPV) infects a variety of mammalian cell types in vitro, but does not replicate in these cells. We investigated the effects of AcMNPV in the induction of the immune response and tumor metastasis in mice. After intravenous injection, AcMNPV was taken up by the liver and spleen, and preferentially infected dendritic cells (DCs) and B cells in the spleen; costimulatory molecules CD40, CD80, and CD86 were upregulated in the DCs. The hepatic mononuclear cells (MNCs) in these animals were highly cytotoxic to natural killer (NK)-sensitive YAC-1 and B16 melanoma cells, but not to NK-resistant EL4 cells. Intravenous injection of AcMNPV-induced NK cell proliferation in the liver and spleen, and enhanced antitumor immunity in mice with B16 liver metastases. Furthermore, such treatment increased the survival of C57BL/6, J alpha 281 (-/-), and interferon (IFN)-gamma (-/-) mice that were previously injected with B16 tumor cells. AcMNPV injection did not enhance the survival of NK cell-depleted mice. Moreover, one AcMNPV treatment effectively prolonged survival in a B16 liver metastasis model, and was equivalent to five treatments with recombinant interleukin-12 (IL-12) protein. These findings suggest that AcMNPV efficiently stimulates NK cell-mediated antitumor immunity.

[A case of gastric cancer with peritoneal dissemination-efficacy of combination therapy with S-1 and docetaxel].

The efficiency of new anti-cancer drugs such as the S-1 system was demonstrated in a controlled study comparing treatment and non-treatment groups. We encountered a patient with gastric cancer demonstrating peritoneal dissemination, who was successfully treated by combination therapy using S-1 and docetaxel. A 62-year-old woman was admitted to the hospital due to appetite loss and nausea. Upper GI endoscopy demonstrated a type 3 gastric cancer extending from the upper to lower body of the stomach. In the pelvic cavity, an abdominal CT scan demonstrated massive ascites. An abnormally high CA72-4 (143.8 U/mL) level was detected in serum. Treatment with S-1 and docetaxel was started with the following regimen: daily oral administration of 80 mg/body S-1 for 14 days, followed by a 7-day rest and infusion of 40 mg/m2 docetaxel on day 1. After 4 courses, the sites of dissemination had disappeared, and the serum CA72-4 value returned to normal. The patient clinically achieved good QOL by this method, which was very effective for non-resected gastric cancer with peritoneal dissemination.

Evaluation of the 5-fluorouracil plasma level in patients with colorectal cancer undergoing continuous infusion chemotherapy.

5-Fluorouracil (5-FU) dosing has traditionally been based on the body surface area (BSA) in colorectal cancer treatment. However, there is accumulating evidence that dosing based on BSA may be of limited use. The purpose of the present study was to evaluate the changes in 5-FU plasma levels and tumor response as well as the severity of adverse events in patients with cancer treated with 5-FU combined chemotherapy. The dosing amount of 5-FU was determined based on the BSA. Blood samples were collected, and 5-FU plasma levels in 15 patients with colorectal cancer were measured three times (0, 22 and 40 h before and after the start of infusion) during constant-infusion of 5-FU for 46 h by an immunoassay. 5-FU plasma levels were significantly higher at 22 and 40 h compared with at 0 h (P<0.001), when all 15 patients were analyzed. Notably, the tumor response of the partial response/stable disease group showed significant increases in 5-FU plasma levels at 40 h compared with at 22 h (P<0.01), while the progressive disease group showed no significant increase. In addition, the 5-FU plasma level in the adverse event level of grade ≥2 was higher than that of grade <2 at 40 h after the start of infusion. Collectively, these observations indicated that during continuous infusion of 5-FU, the 5-FU plasma level increased significantly, and the tumor response (such as partial response, stable or progressive disease) may be influenced by the increase of 5-FU plasma level from the start of infusion. Therefore, the 5-FU plasma level may be a predictive factor for maximizing the tumor response and minimizing the risk of severe adverse events.

Impact of primary tumor location as a predictive factor in patients suffering from colorectal cancer treated with cytotoxic anticancer agents based on the collagen gel droplet-embedded drug sensitivity test.

In recent studies, better clinical outcomes for patients with left-sided colon cancer (CC) compared with right-sided CC have been reported; however, in such investigations, the chemotherapy regimens included molecular-targeting agents. To the best of our knowledge, the impact of primary tumor location as a predictive factor in patients suffering from CC treated with cytotoxic anticancer agents alone has not been investigated. The aim of the present study was to determine the impact of the primary tumor location as a predictive factor of patients undergoing the following cytotoxic anticancer agent regimens: Leucovorin and fluorouracil + oxaliplatin (FOLFOX) or Leucovorin and fluorouracil + irinotecan (FOLFIRI), using the collagen gel droplet-embedded drug sensitivity test (CD-DST). Between March 2008 and April 2017, tumor specimens were obtained from 133 patients suffering from colorectal cancer (CRC) who had not received preoperative chemotherapy. CD-DST was performed and the growth inhibition rate (IR) was determined in FOLFOX and FOLFIRI regimens. The associations between tumor location and IR values for each condition were evaluated. In the present study, the prognosis of patients receiving palliative chemotherapy as well as treatment with molecularly-targeted agents was also investigated. There were no significant differences in the IRs (%) of the two regimens using CD-DST for right-sided tumors compared with left-sided tumors, including or excluding the rectum. The median survival times of patients with right CC and left CC who had received palliative chemotherapy and treatment with molecularly-targeted agents were 960 and 1,348 days, respectively. Primary tumor location did not represent a predictive factor for the efficacy of treatment with cytotoxic anticancer agent regimens using CD-DST. However, patients suffering from left-sided CC were revealed to exhibit better clinical outcomes compared with patients suffering from right-sided CC when molecularly-targeted agent regimens were administered. Therefore, the results of the present study suggested that molecularly-targeted agents rather than cytotoxic anticancer agents may result in improved clinical outcomes for patients with CRC suffering from left-sided tumors.

NQO1 inhibits the TLR-dependent production of selective cytokines by promoting IκB-ζ degradation.

NAD(P)H:quinone oxidoreductase 1 (NQO1) protects cells against oxidative stress and toxic quinones. In this study, we found a novel role of NQO1 in suppressing Toll-like receptor (TLR)-mediated innate immune responses. NQO1-deficient macrophages selectively produced excessive amounts of IL-6, IL-12, and GM-CSF on LPS stimulation, and the deletion of NQO1 in macrophages exacerbated LPS-induced septic shock. NQO1 interacted with the nuclear IκB protein IκB-ζ, which is essential for the TLR-mediated induction of a subset of secondary response genes, including IL-6, and promoted IκB-ζ degradation in a ubiquitin-dependent manner. We demonstrated that PDLIM2, known as the ubiquitin E3 ligase, participates in NQO1-dependent IκB-ζ degradation. NQO1 augmented the association between PDLIM2 and IκB-ζ, resulting in increased IκB-ζ degradation. Collectively, this study describes a mechanism of the NQO1-PDLIM2 complex as a novel and important regulator in the innate immune signaling and suggests the therapeutic potential of NQO1 in TLR-mediated inflammation and disorders.

Impact of the individualization of the first-line chemotherapy for advanced colorectal cancer based on collagen gel droplet-embedded drug sensitivity test.

Leucovorin (FOL) and fluorouracil (5-FU) plus oxaliplatin (l-OHP; FOLFOX) or FOL and 5-FU plus irinotecan (SN-38; FOLFIRI) are widely used as first-line chemotherapy regimens in the treatment of advanced colorectal cancer (CRC). However, second-line chemotherapy must be abandoned in certain cases due to disease progression, adverse effects or high medical cost. Therefore, the most effective regimen should be selected as first-line chemotherapy. We reported that individualization of first-line treatment (FOLFOX/FOLFIRI/Dual/Poor responder) was possible using the collagen gel droplet-embedded culture drug sensitivity test (CD-DST) and that individualized first-line chemotherapy with CD-DST may improve the prognosis of patients with unresectable CRC. The aim of the present prospective cohort study was to evaluate the individualization of first-line chemotherapy using CD-DST, with a focus on prognosis. Between March 2008 and December 2015, tumor specimens were obtained from 120 patients with CRC who had not received preoperative chemotherapy. CD-DST was performed and the growth inhibition rate (IR) was determined by exposure for 24 h with 5-FU and l-OHP (6.0 and 3.0 µg/ml, respectively) and 5-FU and SN-38 (6.0 and 0.2 µg/ml, respectively). The cumulative distribution of IR values under each condition was evaluated on the basis that the clinical response to FOLFOX and FOLFIRI is equivalent (~50%). The prognosis of dual responder was improved compared with that of poor responders, however this difference was identified to be significant. There was no different prognosis between patients treated with an appropriate first-line regimen and patients treated with an inappropriate first-line regimen in dual responders. However, in poor responders, there were significant differences of prognosis between patients treated with an appropriate first-line regimen and patients treated with an inappropriate first-line regimen (P=0.036). In conclusion, the results from the present study suggest that administration of the recommended first-line regimen using CD-DST for patients with unresectable CRC is important for the improvement of prognosis, particularly in poor responders.

The relationship between 5-fluorouracil sensitivity and single nucleotide polymorphisms of the orotate phosphoribosyl transferase gene in colorectal cancer.

Orotate phosphoribosyl transferase (OPRT) is an enzyme playing an important role in exertion of the effect of 5-fluorouracil (5-FU). A type of gene polymorphism, single nucleotide polymorphism (SNP), is considered to be a factor affecting individual differences in exertion of drug effects, and its analysis has recently made progress. We investigated the correlation between SNP of OPRT and 5-FU sensitivity in colon and rectal cancers. The subjects were 31 patients with colorectal cancer who underwent surgical excision between December 2003 and July 2004 at our department. Of SNP of OPRT, 638G/C, 1050T/A, and 1336A/G located in the coding region were analyzed by invader assay. The growth inhibition rate (% IR) of colorectal cancer by 5-FU was obtained by the CDDST method, and 5-FU sensitivity was compared among strains (wild-, homo-, and hetero-types) of each polymorphism. There was no relationship between the strains and 5-FU sensitivity in any of the SNPs. The investigated SNPs of OPRT may have no major influence on 5-FU sensitivity. However, there are many unknown factors in the relationship between SNP of OPRT and 5-FU sensitivity, and SNP analysis of other regions is necessary.

Evaluation of 5-fluorouracil applicability by multi-point collagen gel droplet embedded drug sensitivity test.

The drug sensitivity of tumor cells is one of key issues to explore individualized therapy for cancer patients. One of such methods is in vitro anticancer drug sensitivity test which is generally based on one drug concentration and contact time. In this study, 5-fluorouracil (5-FU) sensitivity of cancer cells from colorectal cancer patients was evaluated by collagen gel droplet embedded drug sensitivity test (CD-DST) under multiple drug concentrations and contact durations. Cancer cells from 19 patients were measured for 9 drug concentration/contact time conditions (cohort 1) and from 34 patients were measured for 2 drug concentration/contact time conditions (cohort 2) using CD-DST. There was not significant difference in growth inhibition rate for 1.0 microg/ml for 24 h and 0.2 microg/ml for 120 h, which gives the same area under the curve (AUC) (p=0.832) in all 53 patients (cohort 1 and 2). In cohort 1, 9 conditions were successfully measured in 18 of 19 cohort 1 patients (94.7%). The drug concentrations and growth inhibition rate approximated to logarithmic curve for all 3 contact times and 50% inhibitory concentration (IC50) values at 3 contact times could be calculated in these 18 patients. Growth inhibition rate and AUC also approximated to logarithmic curve. These values varied several orders of magnitude among patients. In vitro antitumor effect of 5-FU depended on AUC in colorectal tumor and it might support the use of continuous infusion or oral therapy which generates significant AUC with manageable toxicity. Some patients demonstrating low 5-FU sensitivity could not be indicated for 5-FU based therapy, and non-5-FU therapy should be explored for them.