GATA2 hypomorphism induces chronic myelomonocytic leukemia in mice.

The transcription factor GATA2 regulates normal hematopoiesis, particularly in- stem cell maintenance and myeloid differentiation. Various heteroallelic GATA2 gene mutations are associated with a variety of hematological neoplasms, including myelodysplastic syndromes and leukemias. Here, we report that impaired GATA2 expression induces myelodysplastic and myeloproliferative neoplasm development in elderly animals, and this neoplasm resembles chronic myelomonocytic leukemia in humans. GATA2 hypomorphic mutant (G2f GN / fGN ) mice that were generated by the germline insertion of a neocassette into the Gata2 gene locus avoided the early embryonic lethality observed in Gata2-null mice. However, adult G2f GN / fGN mice suffered from exacerbated leukocytosis concomitant with progressive anemia and thrombocytopenia and eventually developed massive granulomonocytosis accompanied by trilineage dysplasia. The reconstitution activity of G2f GN / fGN mouse stem cells was impaired. Furthermore, G2f GN / fGN progenitors showed myeloid lineage-biased proliferation and differentiation. Myeloid progenitor accumulation started at a younger age in G2f GN / fGN mice and appeared to worsen with age. G2f GN / fGN mice showed increased expression of transcripts encoding cytokine receptors, such as macrophage colony-stimulating factor receptor and interleukin-6 receptor, in granulocyte-monocyte progenitors. This increased expression could be correlated with the hypersensitive granulomonocytic proliferation reaction when the mice were exposed to lipopolysaccharide. Taken together, these observations indicate that GATA2 hypomorphism leads to a hyperreactive defense response to infections, and this reaction is attributed to a unique intrinsic cell defect in the regulation of myeloid expansion that increases the risk of hematological neoplasm transformation.

Concomitant Nrf2- and ATF4-activation by Carnosic Acid Cooperatively Induces Expression of Cytoprotective Genes.

: Carnosic acid (CA) is a phytochemical found in some dietary herbs, such as Rosmarinus officinalis L., and possesses antioxidative and anti-microbial properties. We previously demonstrated that CA functions as an activator of nuclear factor, erythroid 2 (NF-E2)-related factor 2 (Nrf2), an oxidative stress-responsive transcription factor in human and rodent cells. CA enhances the expression of nerve growth factor (NGF) and antioxidant genes, such as HO-1 in an Nrf2-dependent manner in U373MG human astrocytoma cells. However, CA also induces NGF gene expression in an Nrf2-independent manner, since 50 µM of CA administration showed striking NGF gene induction compared with the classical Nrf2 inducer tert-butylhydroquinone (tBHQ) in U373MG cells. By comparative transcriptome analysis, we found that CA activates activating transcription factor 4 (ATF4) in addition to Nrf2 at high doses. CA activated ATF4 in phospho-eIF2α- and heme-regulated inhibitor kinase (HRI)-dependent manners, indicating that CA activates ATF4 through the integrated stress response (ISR) pathway. Furthermore, CA activated Nrf2 and ATF4 cooperatively enhanced the expression of NGF and many antioxidant genes while acting independently to certain client genes. Taken together, these results represent a novel mechanism of CA-mediated gene regulation evoked by Nrf2 and ATF4 cooperation.

Prognostic Factors Associated with Preoperative Clinicophysiological Outcomes of Distal Cholangiocarcinoma.

BACKGROUND/AIMS: Although biliary tract cancer is generally associated with a high mortality rate, patients with distal cholangiocarcinoma have better prognoses, compared to those with periampullary cancer. This study aimed to determine the preoperative clinicophysiological factors predictive of survival and recurrence in patients with distal cholangiocarcinoma. METHODS: Forty-five patients (34 men) with distal cholangiocarcinoma who underwent pancreaticoduodenectomy between 2005 and 2013 were examined retrospectively at our center and associated hospitals. Clinicophysiological parameters included predictors of overall survival (OS). Kaplan-Meier survival curves were generated and compared using log-rank tests, and Cox proportional hazard multivariate analyses were performed. RESULTS: The mean patient age was 68.8 years (range 54-81 years). Patients had a median OS duration of 43 months, and 1-, 3-, and 5-year OS rates of 91.1, 61.1, and 40.4%, respectively. Univariate analyses indicated that the body mass index, C-reactive protein (CRP) level, and carcinoembryonic antigen level were independent prognostic factors for OS; however, only the CRP level remained an independent prognostic factor in a multivariate analysis. CONCLUSIONS: A CRP level <0.3 mg/dL was predictive of a better outcome among patients with distal cholangiocarcinoma.

Nrf2 activation is associated with Z-DNA formation in the human HO-1 promoter.

Using a luciferase reporter assay, we previously demonstrated that a Z-DNA-forming sequence of alternating thymine-guanine repeats in the human heme oxygenase-1 gene (HO-1) promoter is involved in nuclear factor erythroid-derived 2 (NF-E2)-related factor 2 (Nrf2)-mediated HO-1 promoter activation. However, the actual Z-DNA formation in this native genomic locus has not been experimentally demonstrated. To detect Z-DNA formation in vivo, we generated a construct containing the Z-DNA-binding domain of human adenosine deaminase acting on double-stranded RNA 1 fused with enhanced green fluorescence protein, designated as the Z-probe. A chromatin immunoprecipitation assay using an anti-GFP antibody showed that the Z-probe detects the well-characterized Z-DNA formation in the CSF1 promoter. Using this detection system, we demonstrated that the glutathione-depleting agent, diethyl maleate, induced Nrf2-dependent Z-DNA formation in the HO-1 promoter, but not in the thioredoxin reductase 1 gene promoter. Moreover, a time course analysis revealed that Z-DNA formation precedes HO-1 transcriptional activation. Concurrent with Z-DNA formation, nucleosome occupancy was reduced, and the recruitment of RNA polymerase II was enhanced in the HO-1 promoter region, suggesting that Z-DNA formation enhances HO-1 gene transcription. Furthermore, Nrf2-induced BRG1 recruitment to the HO-1 promoter temporarily occurred simultaneously with Z-DNA formation. Thus, these results implicate Nrf2-dependent Z-DNA formation in HO-1 transcriptional activation and suggest the involvement of BRG1 in Z-DNA formation.

Efficacy of non-stented pancreaticojejunostomy demonstrated in the hard pancreas.

BACKGROUND/AIMS: The aim of this study was to compare hard and soft pancreas for short-term complications of pancreaticoduodenectomy performed with a duct-to-mucosa anastomosis of pancreaticojejunostomy without a stenting tube. METHODOLOGY: We investigated 156 patients with pancreaticojejunostomy who were classified into two groups of hard pancreas (group A: 79) and soft pancreas (group B: 77). Outcomes, including complications and operative procedures, are reported. RESULTS: There were no differences between groups A and B for median age, gender, performance status. Biliary drainage ratio and disease classification of Groups A and B were statistically different. In preoperative status, there were no differences in Body Mass Index, total bilirubin, albumin, hemoglobin, creatinine, and PFD. Group B had lower HbA1C levels than group A. In operative procedures, there were no differences in operative times and blood loss, but group B had longer postoperative hospital days than group A. On operative results, there were no differences in mortality, delayed gastric emptying, biliary fistula, hemorrhage, cholangitis, lymph leakage, and others. There were significant differences between groups A and B in morbidity (12.7% vs. 35.1%), pancreatic fistula (0% vs. 9.1%), intra-abdominal abscess (1.3% vs. 9.1%). CONCLUSION: Efficacy of pancreaticojejunostomy without a stenting tube for hard pancreas was demonstrated.

Adjuvant chemotherapy using gemcitabine for resected distal bile duct and ampullary cancers.

BACKGROUND/AIMS: This retrospective study aimed to evaluate adjuvant chemotherapy using gemcitabine for resected distal bile duct and ampullary cancers. METHODOLOGY: Thirty-seven patients who had curative surgery for distal bile duct and ampullary cancers were classified into two groups: A, 19, surgery alone, and B, 18, surgery plus gemcitabine adjuvant chemotherapy between 2004 and 2010. Outcomes, including backgrounds, overall survival (OS), disease free survival (DFS), and adverse events are reported. RESULTS: There were no differences in characteristics between patients of groups A and B for age, gender, location of tumor, UICC stage, UICC pT factor, UICC pN factor, curability, and operative procedures. For all stages, except stage II, there was no difference between groups A and B for OS and DFS. For stage II however, groups A and B showed significant differences in median survival times for OS and DFS. Grade 3 or 4 adverse events included 5.6% with leucopenia. CONCLUSIONS: Adjuvant chemotherapy using gemcitabine showed the potential of contributing to prolonged OS and DFS in stage II resected distal bile duct and ampullary cancers. However, a large cohort will be needed to confirm the overall efficacy in all stages of resected BTC's.

Retrospective study of gemcitabine plus S-1 versus gemcitabine alone in cases with unresectable advanced pancreatic cancer.

BACKGROUND/AIMS: The aim of this study was to compare gemcitabine plus S-1 (GS) combination chemotherapy to gemcitabine (GEM) monotherapy in cases with unresectable advanced pancreatic cancer. METHODS: We retrospectively reviewed 107 consecutive patients with unresectable advanced pancreatic cancer who received GEM monotherapy or GS combination chemotherapy between 2004 and 2010. In 73 patients, GEM (1000 mg/m2) was administered intravenously on days 1, 8 and 15, repeated every four weeks. The GS regimen received by 34 patients consisted of intravenous GEM (1000 mg/m2) on days 1 and 8, combined with oral S-1 (40 mg/m2) twice daily on days 1-14, repeated every four weeks. RESULTS: Response rates in the GEM and GS groups (6.8% versus 32.4%) varied significantly, as did disease control rates (28.8% versus 61.8%, respectively). There was a significant difference in median overall survival (206 versus 258 days) and median progression-free survival (86 versus 123 days) between the GEM and GS groups. Grade 3/4 toxicities in both groups were neutropenia (16.4% in GEM, 17.6% in GS), thrombocytopenia (1.3%, 2.9%), anorexia (1.3%, 0%), and diarrhea (1.3%, 0%). CONCLUSIONS: Retrospectively, GS combination therapy is feasible more effective than GEM monotherapy, and therefore should be considered in cases with unresectable advanced pancreatic cancer.

Pancreaticoduodenectomy can be safely performed in the elderly.

BACKGROUND: Although pancreaticoduodenectomy has been recognized in the past for its severe complications, improvements in operative methods and perioperative management have made it a safe procedure. Therefore, pancreaticoduodenectomy can be performed in elderly patients, and our experience and outcomes are described in this report. METHODS: We retrospectively investigated 142 patients in whom pancreaticoduodenectomy was performed without stenting tubes during pancreaticojejunostomy. The patients were classified into two groups: (A) those older and (B) younger than 75 years. The outcomes, including preoperative characteristics, intraoperative characteristics, postoperative complications and mortality, are herein reported. Continuous variables were compared using Student's t test and the Chi-square test. RESULTS: There were no differences between groups A and B in terms of sex, operative time, amount of blood loss, performance status, soft pancreas rate, disease distribution and operative procedure. Comorbidities in groups A and B were statistically different. Regarding the preoperative status, the elderly patients exhibited lower serum albumin and hemoglobin levels than the younger patients. There were no differences in mortality (0 vs. 0 %), morbidity (24.3 vs. 29.5 %, p = 0.362), postoperative hospital days or major complications such as pancreatic fistula development, delayed gastric emptying, intra-abdominal abscess development, biliary fistula formation and postpancreatectomy hemorrhage. CONCLUSIONS: Pancreaticoduodenectomy can be safely performed in elderly as well as younger patients.

The novel Nrf2-interacting factor KAP1 regulates susceptibility to oxidative stress by promoting the Nrf2-mediated cytoprotective response.

The transcription factor Nrf2 (nuclear factor-erythroid 2-related factor 2) co-ordinately regulates ARE (antioxidant-response element)-mediated induction of cytoprotective genes in response to electrophiles and oxidative stress; however, the molecular mechanism controlling Nrf2-dependent gene expression is not fully understood. To identify factors that regulate Nrf2-dependent transcription, we searched for proteins that interact with the Nrf2-NT (N-terminal Nrf2 transactivation domain) by affinity purification from HeLa nuclear extracts. In the present study, we identified KAP1 [KRAB (Krüppel-associated box)-associated protein 1] as a novel Nrf2-NT-interacting protein. Pull-down analysis confirmed the interaction between KAP1 and Nrf2 in cultured cells and demonstrated that the N-terminal region of KAP1 binds to Nrf2-NT in vitro. Reporter assays showed that KAP1 facilitates Nrf2 transactivation activity in a dose-dependent manner. Furthermore, the induction of the Nrf2-dependent expression of HO-1 (haem oxygenase-1) and NQO1 [NAD(P)H quinone oxidoreductase 1] by DEM (diethyl maleate) was attenuated by KAP1 knockdown in NIH 3T3 fibroblasts. This finding established that KAP1 acts as a positive regulator of Nrf2. Although Nrf2 nuclear accumulation was unaffected by KAP1 knockdown, the ability of Nrf2 to bind to the regulatory region of HO-1 and NQO1 was reduced. Moreover, KAP1 knockdown enhanced the sensitivity of NIH 3T3 cells to tert-butylhydroquinone, H2O2 and diamide. These results support our contention that KAP1 participates in the oxidative stress response by maximizing Nrf2-dependent transcription.

[A case of bile duct cancer with positive surgical margin obtaining long-term survival after S-1 monotherapy].

We report a case of bile duct cancer with a positive surgical margin obtaining long-term survival after S-1 monotherapy. A 79-year-old male with fever and liver dysfunction was admitted to our hospital. After a series of examinations he was diagnosed as hilar cholangiocarcinoma, which was treated with bile duct resection and biliary reconstruction for adhesion and pulmonary dysfunction of tuberculosis. Histopathological findings revealed that both surgical margins of the bile duct were positive. After operation, the patient received S-1 oral monotherapy(100mg/day for 28 days, followed by 14 days of rest)for 3 years. The patient has been alive for 5 years without recurrence.

Nrf2 regulates ferroportin 1-mediated iron efflux and counteracts lipopolysaccharide-induced ferroportin 1 mRNA suppression in macrophages.

Iron is an essential element of hemoglobin, and efficient iron recycling from senescent erythrocytes by splenic macrophages is required for erythrocyte hemoglobin synthesis during erythropoiesis. Ferroportin 1 (Fpn1) is the sole iron exporter in mammals, and it also regulates iron reutilization. In this study, we demonstrated genetically that a redox-sensitive transcription factor, Nrf2, regulates Fpn1 mRNA expression in macrophages. Nrf2 activation by several electrophilic compounds commonly resulted in the upregulation of Fpn1 mRNA in bone marrow-derived and peritoneal macrophages obtained from wild-type mice but not from Nrf2 knockout mice. Further, Nrf2 activation enhanced iron release from the J774.1 murine macrophage cell line. Previous studies showed that inflammatory stimuli, such as LPS, downregulates macrophage Fpn1 by transcriptional and hepcidin-mediated post-translational mechanisms leading to iron sequestration by macrophages. We showed that two Nrf2 activators, diethyl maleate and sulforaphane (SFN; a natural Nrf2 activator found in broccoli), restored the LPS-induced suppression of Fpn1 mRNA in human and mouse macrophages, respectively. Furthermore, SFN counteracted the LPS-induced increase of Hepcidin mRNA by an Nrf2-independent mechanism in mouse peritoneal macrophages. These results demonstrate that Nrf2 regulates iron efflux from macrophages through Fpn1 gene transcription and suggest that Nrf2 may control iron metabolism during inflammation.

[Effectiveness of adjuvant chemotherapy using gemcitabine for resected pancreatic cancer].

BACKGROUND: The aim was to evaluate the adjuvant chemotherapy using gemcitabine (GEM) for resected pancreatic cancer. METHODS: We investigated 69 patients who had undergone curative operations for pancreatic cancer. They were classified into two groups of patients using GEM (group A: 37) and patients with surgery alone (group B: 32) between 2009 and 1998. Outcomes, including disease-free survival (DFS), median survival time (MST), and adverse events were reported retrospectively. Patients assigned to the gemcitabine group received GEM at a dose of 800 mg/m² on days 1, 8 and 15, every 4 weeks for 5 cycles. RESULTS: DFS and MST did not differ significantly between group A and group B (DFS; group A: 10. 4 vs group B 8. 0 months, MST; group A: 21. 7 vs group B 16. 3 months). The estimated overall survival rates at 3 and 5 years were 40% and 25. 7%, respectively, in group A, and 12. 9% and 12. 9% in group B. Grade 3 or 4 toxicity revealed 8.1%with leucopenia, 2. 7% with thrombocytopenia, and 2. 7% with nausea. RESULTS: Adjuvant chemotherapy using gemcitabine for resected pancreatic cancer contributes to prolonged DFS, MST, and estimated overall survival.

Pancreatic schwannoma: a case report and literature review with special reference to imaging features.

CONTEXT: We report the imaging features of pancreatic schwannomas, a rare benign type of pancreatic tumor. CASE REPORT: A 66-year-old woman was admitted to our hospital with a pancreatic tumor indicated in medical examinations. Computed tomography (CT), magnetic resonance imaging (MRI) and endoscopic ultrasonography (EUS) revealed a solid and cystic tumor, 3 cm in diameter, within the body of the pancreas. Contrast-enhanced CT, MRI and ultrasonography showed partial enhancement in the solid component. Endoscopic retrograde cholangiopancreatography (ERCP) and angiography showed no abnormal findings. A distal pancreatectomy together with a splenectomy and lymph node dissection were performed with a tentative diagnosis of mucinous cystic neoplasm of the pancreas. The cut surface of the resected pancreas showed a well-demarcated, pale yellow, solid tumor within the pancreas parenchyma. Histopathological examination of the tumor revealed proliferation of the spindle cells showing interlacing and palisading patterns. Immunohistochemically, these spindle cells were positive for S-100 protein and vimentin, and negative for alpha-smooth muscle actin, CD34, and cytokeratin. Thus the tumor was diagnosed as a pancreatic schwannoma. CONCLUSION: CT and US can detect pancreatic schwannomas as solid and cystic masses, and MRI shows a relatively characteristic feature. Imaging procedures such as CT, MRI and US are able to differentiate a pancreatic tumor, such as a pancreatic schwannoma.

[Risk associated with severe hematological toxicity in patients with advanced or recurrent colonic cancer receiving combination chemotherapy of S-1 and irinotecan hydrochloride].

The aim of this study was to analyze the risk factors for grade 3 to 4 hematological toxicity after primary chemotherapy (Tegafur, gimeracil, oteracil potassium (S-1)/irinotecan hydrochloride (CPT-11)) in 87 (56 male, 31 female; median age 66.1 years) patients with unresectable or recurrent colonic cancer between April 2005 and May 2009, and to prepare a risk classes (low-risk, intermediate-risk or high-risk groups). The rate of grade 3 to 4 hematological toxicity was 16.1%. At multivariate analysis, risk factors for grade 3 to 4 hematological toxicity were baseline WBC, Cr, female (p<0.05). The toxicity index (TI) consisted of risk factors and regression coefficient. We were stratified patients into three groups according to TI that was calculated for each patient. The group with high value was found to include patients with grade 3 to 4 hematological toxicity with a significantly higher frequency than the group with low value (4.2% vs 57.1%, p=0.004). This risk classes could be useful to identify patients at high risk for chemotherapy-induced grade 3 to 4 hematological toxicity.

Author Correction: Nrf2 contributes to the weight gain of mice during space travel.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Nrf2 contributes to the weight gain of mice during space travel.

Space flight produces an extreme environment with unique stressors, but little is known about how our body responds to these stresses. While there are many intractable limitations for in-flight space research, some can be overcome by utilizing gene knockout-disease model mice. Here, we report how deletion of Nrf2, a master regulator of stress defense pathways, affects the health of mice transported for a stay in the International Space Station (ISS). After 31 days in the ISS, all flight mice returned safely to Earth. Transcriptome and metabolome analyses revealed that the stresses of space travel evoked ageing-like changes of plasma metabolites and activated the Nrf2 signaling pathway. Especially, Nrf2 was found to be important for maintaining homeostasis of white adipose tissues. This study opens approaches for future space research utilizing murine gene knockout-disease models, and provides insights into mitigating space-induced stresses that limit the further exploration of space by humans.

Keap1/Nrf2 system regulates neuronal survival as revealed through study of keap1 gene-knockout mice.

Keap1 is proposed to be a sensor protein of electrophilic compounds and a transducer of the signal from electrophilic compounds for transcriptional activation. Thus, the use of keap1 gene-knockout (KO) mice is a straightforward approach in order to clarify the molecular background for the use of electrophilies as neuroprotective compounds. In the present report, we investigated the question as to how the deletion of the keap1 gene affects the activities of Nrf2 and survival of immature cortical neurons. In cortical cultures prepared from wild-type (WT) mice, Keap1 was expressed in the neurons, and Nrf2 protein was retained in their cytoplasm; whereas Nrf2 was translocated into the nuclei of neurons and phase 2 enzymes were constitutively activated in the cortical cultures from KO mice. Consistent with these results, cortical neurons from KO mice showed increased resistance to oxidative stress induced by high concentrations of glutamate and rotenone. These results suggest that the absence of Keap1 constitutively activates Nrf2, which then induces the phase 2 enzymes in neurons and induces increased resistance of cortical neurons to oxidative stress. This report is the first report to show that Keap1 is a key regulator of cell defense mechanisms of CNS neurons against oxidative stress.

[Risk associated with severe hematological toxicity in patients with advanced or recurrent gastric cancer receiving primary combination chemotherapy of cisplatin and S-1 or cisplatin and irinotecan hydrochloride].

The purpose of this study was to analyze the risk factor for grade 3 to 4 hematological toxicity after primary chemotherapy(cisplatin(CDDP)/tegafur, gimeracil, oteracil potassium(S1)or CDDP/irinotecan hydrochloride(CPT-11)) in 75 patients with unresectable or recurrent gastric cancer between April 2005 and May 2008. The rate of grade 3 to 4 hematological toxicity was 17.3%(13 patients). Grade 3 to 4 hematological toxicity was the endpoint selected for the analysis. At multivariate analysis, the most important pretreatment risk factors for grade 3 to 4 hematological toxicity in patients receiving primary chemotherapy of unresectable or recurrent gastric cancer were found to be hemoglobin(OR 0.520; p=0.012)and treatment regimen(CDDP/CPT-11)(OR 0.101; p=0.002). Therefore, patients about to receive chemotherapy should be considered in these risk factors.

[A case of pathologic complete response of primary esophageal carcinoma treated with 5-FU/CDDP as neoadjuvant chemotherapy].

A 77-year-old man with advanced esophageal carcinoma and lymph node swelling of abdomen and mediastinum, underwent neoadjuvant chemotherapy (NAC) with 5-FU/CDDP. Adverse reactions were general fatigue and nausea of grade 3 and stomatitis of grade 2. Primary tumor and lymph node swelling revealed remarkable effectiveness after 1 course of NAC, so 2 courses of NAC were given. The esophageal carcinoma was not found by endoscopy, and a biopsy specimen revealed inflammatory granulation. Lymph node on CT examination disappeared in the abdomen and reduced in the mediastinum. Because of retention of lymph node swelling, radical resection of the esophageal carcinoma was performed. Pathologic examination of the resected specimen revealed no malignant cells in the esophagus, and 3 lymph node metastases (pStage III). He had no recurrence in 15 months after the operation. Because NAC was markedly effective for primary tumor and lymph node of esophageal carcinoma, a radical operation was performed.

Number of positive lymph nodes and lymphatic invasion are significant prognostic factors after pancreaticoduodenectomy for distal cholangiocarcinoma.

Background: Early recurrence of distal cholangiocarcinoma (DCC) may result in a poorer prognosis. This study aimed to evaluate the clinicopathological factors that predict survival and recurrence in patients with DCC. Methods: Fifty-five patients with DCC who underwent pancreaticoduodenectomy between 2005 and 2015 were studied retrospectively. The following clinicopathological parameters were analyzed as predictors of disease-free survival (DFS) and overall survival (OS): sex, age, body mass index, presence of biliary tract decompression, macroscopic type, histological type, tumor size, TNM classification, lymph node metastasis ratio, number of positive lymph nodes (PLNs), lymphatic invasion, venous invasion, perineural invasion, proximal bile duct margin, dissected margin, portal system invasion, arterial system invasion, stage, and residual tumor. Results: Univariate analysis showed that contiguous extension of the primary tumor, PLN, lymphatic invasion, venous invasion, perineural invasion, and stage were significant prognostic factors for DFS and OS. Multivariate analysis revealed that PLN and lymphatic invasion were prognostic for DFS and OS (P<0.001). Significant differences in OS and DFS were found in analyses stratified by PLN (0, 1, 2 vs ≥3) and lymphatic invasion (0 vs 1, 2, 3). Conclusion: Among the clinicopathological parameters analyzed, PLN and lymphatic invasion were confirmed as prognostic factors for DCC.