Comparison of novel DXA system, Shimazu SONIALVISION G4, with GE-Lunar PRODIGY.

INTRODUCTION: SONIALVISION G4 (Shimadzu, Kyoto, Japan) is a fluoroscopic imaging system capable of dual-energy X-ray absorptiometry (DXA) using the additional application. However, bone mineral density (BMD) with this system is calibrated only by a phantom, and the necessity to confirm the reliability of BMD measurement in human subjects has been pointed out. This study aimed to evaluate the clinical reliability of BMD measurement using SONIALVISION G4 by comparing it with PRODIGY (GE Healthcare, Madison, WI, USA), a reference system in developing the DXA application. MATERIALS AND METHODS: BMD measurements using these two DXA systems were performed on the same day at the lumbar spine and bilateral proximal femur of 130 subjects aged 22-86 years. The agreement and correlation between the measurements were determined. Thirty out of the 130 subjects were scanned twice to determine the precision of the SONIALVISION G4 system. RESULTS: BMD was highly correlated between the two DXA systems both at the lumbar spine and proximal femur, with correlation coefficients ranging from 0.963 (left total hip) to 0.989 (left femoral neck). Differences in BMD measured by the two systems were less than 3.0%, but a small proportional bias was observed in the Bland-Altman analysis. Coefficients of variation in BMD measurement were 1.77% in the lumbar spine and 1.41-2.76% in the proximal femur. CONCLUSIONS: Although BMD values by SONIALVISION G4 were close to those by PRODIGY, follow-up studies should be performed using the same device because of the small difference between devices.

Controlled growth of boron-doped epitaxial graphene by thermal decomposition of a B4C thin film.

We show that boron-doped epitaxial graphene can be successfully grown by thermal decomposition of a boron carbide thin film, which can also be epitaxially grown on a silicon carbide substrate. The interfaces of B4C on SiC and graphene on B4C had a fixed orientation relation, having a local stable structure with no dangling bonds. The first carbon layer on B4C acts as a buffer layer, and the overlaying carbon layers are graphene. Graphene on B4C was highly boron doped, and the hole concentration could be controlled over a wide range of 2 × 1013 to 2 × 1015 cm-2. Highly boron-doped graphene exhibited a spin-glass behavior, which suggests the presence of local antiferromagnetic ordering in the spin-frustration system. Thermal decomposition of carbides holds the promise of being a technique to obtain a new class of wafer-scale functional epitaxial graphene for various applications.

A Multidisciplinary Approach to the Management of Chronic Pain through a Self-managed Behavioral Exercise Program : A Pilot Study in Japan.

We conducted this study to determine the short-term treatment outcomes of multidisciplinary approaches to chronic pain management for outpatients in Japan. We evaluated pain reduction and improvement in quality of life (QOL) after treatment. We analyzed 32 patients who had experienced intractable chronic pain for > 3 months. The patients received multidisciplinary therapeutic self-managed exercise instructions and then underwent evaluations 1 and 3 months after the treatment. We used the Pain Disability Short Form-36 (SF-36), Pain Catastrophizing Scale (PCS), and Pain Disability Assessment Scale (PDAS) to evaluate QOL. Although the pain levels were the same before and after the physical exercise program, the patients showed significant improvements in physical function on the SF-36 (48.5 vs. 54.5, 3 months vs. 1 month; p=0.0124), the magnification subscale on the PCS (6.8 vs. 5.9, 1 month vs. before; p=0.0164) and the PDAS (29.2 vs. 23.4, 3 months vs. before; p=0.0055). Chronic pain should be treated with a biopsychosocial approach, but time constraints and costs have limited the implementation of multidisciplinary and behavioral approaches to chronic pain management. Our findings demonstrate that clinical improvements are possible for patients with chronic pain, using multidisciplinary team resources widely available in Japanese clinical practice.

Design and synthesis of 1H-pyrazolo[3,4-c]pyridine derivatives as a novel structural class of potent GPR119 agonists.

Design and synthesis of a novel class of 1H-pyrazolo[3,4-c]pyridine GPR119 receptor agonists are described. Lead compound 4 was identified through the ligand-based drug design approach. Modification of the left-hand aryl group (R(1)) and right-hand piperidine N-capping group (R(2)) led to the identification of compound 24 as a single-digit nanomolar GPR119 agonist.

Discovery of 3-Chloro-N-{(S)-[3-(1-ethyl-1H-pyrazol-4-yl)phenyl][(2S)-piperidine-2-yl]methyl}-4-(trifluoromethyl)pyridine-2-carboxamide as a Potent Glycine Transporter 1 Inhibitor.

A novel glycine transporter 1 (GlyT1) inhibitor was designed by the superposition of different chemotypes to enhance its inhibitory activity. Starting from 2-chloro-N-{(S)-phenyl[(2S)-piperidin-2-yl]methyl}-3-(trifluoromethyl)benzamide (2, SSR504734), the introduction of heteroaromatic rings enabled an increase in the GlyT1 inhibitory activity. Subsequent optimization led to the identification of 3-chloro-N-{(S)-[3-(1-ethyl-1H-pyrazol-4-yl)phenyl][(2S)-piperidine-2-yl]methyl}-4-(trifluoromethyl)pyridine-2-carboxamide (7w), which showed a powerful GlyT1 inhibitory activity (IC50=1.8 nM), good plasma exposure and a plasma to brain penetration in rats that was sufficient to evaluate the compound's pharmacological properties. Compound 7w showed significant effects in several rodent models for schizophrenia without causing any undesirable central nervous system side effects.

[Switching from oral oxycodone to oxycodone injection - an investigation into the dosage amount ratio].

In switching from oraloxycodone to oxycodone injection, clinical guidelines recommend a conversion dose ratio of 0.75. However, in clinical sites, a higher dosage may be needed due to characteristics of cancer pain. In the present study, we investigated changing the dosage amount of oxycodone before and after switching from oraloxycodone administration to oxycodone injection in patients (n=14) who reported suffering from cancer pain. As a result, we found the ratio of the amount used after switching to be 0.91 ± 0.25 (mean ± SD) on the first day, increasing to 1.46 ± 0.48 on the fifth day. Our findings suggest that the dosage amount was the correct one for each patient's condition and also that adequate injection dosage to manage cancer pain was greater than that of calculated by the conversion ratio.

Multidisciplinary management of small cell carcinoma of the breast: a case report.

We report a case of primary small cell carcinoma (SCC) of the breast in a 59-year-old female. To the best of our knowledge, there are only 44 cases of this disease reported in the English literature. The patient also had regional nodal metastases, but no distant metastases. She underwent neoadjuvant chemotherapy according to a regimen of pulmonary SCC, and combination of cisplatin and etoposide (CDDP+VP16). The tumor partially responded to neoadjuvant chemotherapy. The treatment was followed by modified radical mastectomy and adjuvant chemotherapy, i.e., EC therapy (epirubicin and cyclophosphamide). She was also administered in total 50 Gy of radiation treatment to the chest wall. At this writing, the patient has evidenced no recurrence 36 months after her diagnosis.

An awareness survey of surgeons involved in breast cancer treatment regarding their patients returning to work.

Surgeons focus on the period of absence from work during the initial treatment of breast cancer. The aim of this study was to determine surgeons' perceptions and awareness regarding the necessary period of absence from work during breast cancer treatment. We created a questionnaire for all surgeons involved in breast cancer treatment who are affiliated with the Department of Surgery at the Nagoya University Graduate School of Medicine and its associated facilities. The necessary leave of absence period for each treatment was considered, and the decision regarding whether patients should return to work was examined. The surgeons were instructed to assume that a 'heavy load worker' was a nurse or caregiver and that a 'light load worker' was a medical office worker. This study included 184 surgeons (response rate: 96.8%). More than half of the surgeons considered that light load workers could return to work within 2 weeks; 89.8% after conservative resection, 71.6% after total mastectomy, 50.3% after axillary dissection. In contrast, more than half of the surgeons considered that heavy load worker should wait returning to work more than 3 weeks; 49.4% after conservative resection, 73.3% after total mastectomy, 85.7% after axillary dissection. For patients treated with chemotherapy, three-quarters of the surgeons indicated that it would be difficult to work while receiving anthracycline regimens. The results suggest that surgeons can predict the approximate period of absence from work for patients who receive an initial treatment of breast cancer.

Subanalgesic ketamine enhances morphine-induced antinociceptive activity without cortical dysfunction in rats.

PURPOSE: Ketamine, a noncompetitive N-methyl-D-aspartate receptor antagonist, has been used for the treatment of cancer pain as an analgesic adjuvant to opioids. However, ketamine is known to produce psychotomimetic side effects including cognitive impairments under a high-dose situation, presumably as the result of cortical dysfunction. Here, we investigated whether low-dose ketamine was useful as an analgesic adjuvant to morphine for pain control, focusing on frontocortical function. METHODS: To assess the analgesic effects of ketamine with or without morphine, we performed behavioral and histochemical experiments, using the hot plate test and c-Fos expression analysis in rats. The effect on cortical function was also determined by prepulse inhibition (PPI) of the acoustic startle and evoked potentials in the hippocampal CA1-medial prefrontal cortex (mPFC) synapses as measures of synaptic efficacy. RESULTS: Coadministration of ketamine as a subanalgesic dose significantly enhanced intraperitoneal morphine-induced antinociceptive response, which was measured as the increased reaction latency in the hot plate test. In addition, the noxious thermal stimulus-induced c-Fos expression in the ventrolateral periaqueductal gray matter was significantly suppressed by concomitant ketamine and morphine. In contrast, the subanalgesic dose of ketamine did not impair PPI and synaptic efficacy in the mPFC. CONCLUSION: The present results indicate that the morphine-induced analgesic effect is enhanced by a concomitant subanalgesic dose of ketamine without affecting cortical function. Our findings possibly support the clinical notion that low-dose ketamine as an analgesic adjuvant has therapeutic potential to reduce opioid dosage, thereby improving the quality of life in cancer pain patients.

Hydrogen-driven asymmetric reduction of hydroxyacetone to (R)-1,2-propanediol by Ralstonia eutropha transformant expressing alcohol dehydrogenase from Kluyveromyces lactis.

BACKGROUND: Conversion of industrial processes to more nature-friendly modes is a crucial subject for achieving sustainable development. Utilization of hydrogen-oxidation reactions by hydrogenase as a driving force of bioprocess reaction can be an environmentally ideal method because the reaction creates no pollutants. We expressed NAD-dependent alcohol dehydrogenase from Kluyveromyces lactis in a hydrogen-oxidizing bacterium: Ralstonia eutropha. This is the first report of hydrogen-driven in vivo coupling reaction of the alcohol dehydrogenase and indigenous soluble NAD-reducing hydrogenase. Asymmetric reduction of hydroxyacetone to (R)-1,2-propanediol, which is a commercial building block for antibacterial agents, was performed using the transformant as the microbial cell catalyst. RESULTS: The two enzymes coupled in vitro in vials without a marked decrease of reactivity during the 20 hr reaction because of the hydrogenase reaction, which generates no by-product that affects enzymes. Alcohol dehydrogenase was expressed functionally in R. eutropha in an activity level equivalent to that of indigenous NAD-reducing hydrogenase under the hydrogenase promoter. The hydrogen-driven in vivo coupling reaction proceeded only by the transformant cell without exogenous addition of a cofactor. The decrease of reaction velocity at higher concentration of hydroxyacetone was markedly reduced by application of an in vivo coupling system. Production of (R)-1,2-propanediol (99.8% e.e.) reached 67.7 g/l in 76 hr with almost a constant rate using a jar fermenter. The reaction velocity under 10% PH2 was almost equivalent to that under 100% hydrogen, indicating the availability of crude hydrogen gas from various sources. The in vivo coupling system enabled cell-recycling as catalysts. CONCLUSIONS: Asymmetric reduction of hydroxyacetone by a coupling reaction of the two enzymes continued in both in vitro and in vivo systems in the presence of hydrogen. The in vivo reaction system using R. eutropha transformant expressing heterologous alcohol dehydrogenase showed advantages for practical usage relative to the in vitro coupling system. The results suggest a hopeful perspective of the hydrogen-driven bioprocess as an environmentally outstanding method to achieve industrial green innovation. Hydrogen-oxidizing bacteria can be useful hosts for the development of hydrogen-driven microbial cell factories.

Postoperative function following radical surgery in gastric and colorectal cancer patients over 80 years of age--an objection to "ageism".

PURPOSE: With rapid growth in the elderly population, the number of elderly cancer patients who should be offered life-prolonging radical surgery has been increasing. The aim of this report is to demonstrate the outcome of elective radical surgery for gastric or colorectal cancer patients 80 years of age or older, including the natural course of recovery of functional independence, in order to avoid the negative attitude held toward surgery that is due only to patients' high chronological age. METHODS: Physical condition, ADL, and QOL of 108 patients 80 years of age or older with gastric or colorectal cancer were evaluated preoperatively and at the 1st, 3rd, and 6th postoperative months. RESULTS: There were no operative deaths, and the morbidity rate was 27.9%. Only 6% of the patients showed a decrease in ADL at the 6th postoperative month. This decrease typically occurred following discharge from the hospital. Patient QOL showed recovery to an extent equal to or better than average preoperative scores. CONCLUSIONS: Of the patients who underwent elective surgery for gastric or colorectal cancer, only a few showed a protracted decline in ADL, and most exhibited better QOL after surgery. Surgical treatment should therefore be considered, whenever needed, for elderly patients 80 years of age or older with gastric or colorectal cancer.

Free-energy function for discriminating the native fold of a protein from misfolded decoys.

In this study, free-energy function (FEF) for discriminating the native fold of a protein from misfolded decoys was investigated. It is a physics-based function using an all-atom model, which comprises the hydration entropy (HE) and the total dehydration penalty (TDP). The HE is calculated using a hybrid of a statistical-mechanical theory applied to a molecular model for water and the morphometric approach. The energetic component is suitably taken into account in a simple manner as the TDP. On the basis of the results from a careful test of the FEF, which have been performed for 118 proteins in representative decoy sets, we show that its performance is distinctly superior to that of any other function. The FEF varies largely from model to model for the candidate models for the native structure (NS) obtained from nuclear magnetic resonance experiments, but we can find models or a model for which the FEF becomes lower than for any of the decoy structures. A decoy set is not suited to the test of a free-energy or potential function in cases where a protein isolated from a protein complex is considered and the structure in the complex is used as the model NS of the isolated protein without any change or where portions of the terminus sides of a protein are removed and the percentage of the secondary structures lost due to the removal is significantly high. As these findings are made possible, we can assume that our FEF precisely captures the features of the true NS.

Effects of heme on the thermal stability of mesophilic and thermophilic cytochromes c: comparison between experimental and theoretical results.

We have recently proposed a measure of the thermal stability of a protein: the water-entropy gain at 25 °C upon folding normalized by the number of residues, which is calculated using a hybrid of the angle-dependent integral equation theory combined with the multipolar water model and the morphometric approach. A protein with a larger value of the measure is thermally more stable. Here we extend the study to analyses on the effects of heme on the thermal stability of four cytochromes c (PA c(551), PH c(552), HT c(552), and AA c(555)) whose denaturation temperatures are considerably different from one another despite that they share significantly high sequence homology and similar three-dimensional folds. The major conclusions are as follows. For all the four cytochromes c, the thermal stability is largely enhanced by the heme binding in terms of the water entropy. For the holo states, the measure is the largest for AA c(555). However, AA c(555) has the lowest packing efficiency of heme and the apo polypeptide with hololike structure, which is unfavorable for the water entropy. The highest stability of AA c(555) is ascribed primarily to the highest efficiency of side-chain packing of the apo polypeptide itself. We argue for all the four cytochromes c that due to covalent heme linkages, the number of accessible conformations of the denatured state is decreased by the steric hindrance of heme, and the conformational-entropy loss upon folding becomes smaller, leading to an enhancement of the thermal stability. As for the apo state modeled as the native structure whose heme is removed, AA c(555) has a much larger value of the measure than the other three. Overall, the theoretical results are quite consistent with the experimental observations (e.g., at 25 °C the α-helix content of the apo state of AA c(555) is almost equal to that of the holo state while almost all helices are collapsed in the apo states of PA c(551), PH c(552), and HT c(552)).

[A case of spindle cell carcinoma of the breast, in which irinotecan was effective against respiratory failure due to pulmonary metastases].

We present our experience with chemotherapy using irinotecan for lung metastases of spindle cell carcinoma of the breast. The patient is a 50-year-old female, who consulted our hospital due to a large breast tumor about 7 cm in diameter. Although computed tomography revealed invasion to the chest wall, no distant metastases were confirmed. Chemotherapy (FEC100 followed by paclitaxel) was not effective for down-staging. To improve her quality of life, standard radical mastectomy with combined partial resection of the chest wall was performed. The tumor was histologically diagnosed as spindle cell carcinoma. After the operation, multiple lung metastases appeared, and she had severe dyspnea. Thereafter irinotecan was administered. One week after the administration, metastatic lesions were reduced so that her dyspnea was remarkably relieved. The patient continued to receive irinotecan weekly until she died on the 49th day of treatment with irinotecan.

L-type amino acid transporter 1 inhibitors inhibit tumor cell growth.

Most tumor cell membranes overexpress L-type amino acid transporter 1, while normal cell membranes contain l-type amino acid transporter 2; both are Na(+)-independent amino acid transporters. Therefore, compounds that selectively inhibit L-type amino acid transporter 1 offer researchers with a novel cancer molecular target. Synthetic chemistry efforts and in vitro screening have produced a variety of novel compounds possessing high in vitrol-type amino acid transporter 1 selectivity; KYT-0353 was one such compound. The present studies illustrate that KYT-0353 inhibited (14)C-leucine uptake and cell growth in human colon cancer-derived HT-29 cells; IC(50)s were 0.06 microm and 4.1 microm, respectively. KYT-0353 also inhibited (14)C-leucine uptake in mouse renal proximal tubule cells expressing l-type amino acid transporter 1, and inhibited cell growth; IC(50)s were 0.14 microm and 16.4 microm, respectively. Compared to control animals, intravenously administered KYT-0353 (12.5 mg/kg and 25.0 mg/kg) showed statistically significant growth inhibition against HT-29 tumors transplanted to nude mice with maximal inhibition ratios of 65.9% and 77.2%, respectively. Body weight increase with time--a safety indicator--was slightly depressed at 12.5 mg/kg and 25.0 mg/kg with maximal ratios of 3.7% (day 2) and 6.3% (day 11), respectively. Thus, KYT-0353 showed significant growth inhibitory effects on HT-29 cells both in vitro and in vivo, whereas it only caused a slight body weight depression. Therefore, KYT-0353 appears to have potential as a novel anti-tumor agent, presumably via selective in vivol-type amino acid transporter 1 inhibition.

Cytoplasmic expression of the JM403 antigen GlcA-GlcNH3+ on heparan sulfate glycosaminoglycan in mammary carcinomas--a novel proliferative biomarker for breast cancers with high malignancy.

The expressions of heparan sulfate glycosaminoglycans (HSGAGs) in breast carcinoma specimens from 60 patients were immunohistochemically investigated using monoclonal antibodies (mAbs) that recognized different epitopes of the glycan structure. Cytoplasmic expression of GlcA-GlcNH(3)(+) on HSGAG was detected in carcinomas at high frequency (58.3%) using mAb JM403, whereas it was almost undetectable in normal breast ducts. This cytoplasmic expression was confirmed using confocal laser scanning microscopy. The expression of JM403 antigen in invasive carcinomas significantly correlated with nuclear atypia score (p = 0.0004), mitotic counts score (p = 0.0018), nuclear grade (p = 0.0061) and the incidence of metastasis to axillary lymph nodes (p = 0.0061). Furthermore, its expression was significantly correlated with the Ki67-labeling index in 55 invasive carcinomas (p < 0.05) as well as in 26 non-invasive carcinomas (5 non-invasive carcinomas and 21 non-invasive carcinomas that were observed in individual invasive carcinomas) (p < 0.005). Interestingly, the JM403 antigen GlcA-GlcNH(3)(+) was also expressed in the cytoplasm of normal crypt epithelial cells where Ki67 protein was expressed in the cell nuclei in the proliferative compartment of the human small intestines. To date, HSGAGs have generally been found to exist on cell surface membranes and in extracellular matrices as components of HS proteoglycans, and the negatively-charged sulfated domains on HSGAGs are considered to be important for their functions. However, our present findings indicate that the cytoplasmic expression of the JM403 antigen GlcA-GlcNH(3)(+) on positively charged, non-sulfated HSGAG may be involved in cell proliferation and associated with increased degrees of malignancy. The unordinary carbohydrate antigen of GlcA-GlcNH(3)(+) on HSGAGs recognized by mAb JM403 may represent a novel proliferative biomarker for highly malignant mammary carcinomas.

Free-energy function based on an all-atom model for proteins.

We have developed a free-energy function based on an all-atom model for proteins. It comprises two components, the hydration entropy (HE) and the total dehydration penalty (TDP). Upon a transition to a more compact structure, the number of accessible configurations arising from the translational displacement of water molecules in the system increases, leading to a water-entropy gain. To fully account for this effect, the HE is calculated using a statistical-mechanical theory applied to a molecular model for water. The TDP corresponds to the sum of the hydration energy and the protein intramolecular energy when a fully extended structure, which possesses the maximum number of hydrogen bonds with water molecules and no intramolecular hydrogen bonds, is chosen as the standard one. When a donor and an acceptor (e.g., N and O, respectively) are buried in the interior after the break of hydrogen bonds with water molecules, if they form an intramolecular hydrogen bond, no penalty is imposed. When a donor or an acceptor is buried with no intramolecular hydrogen bond formed, an energetic penalty is imposed. We examine all the donors and acceptors for backbone-backbone, backbone-side chain, and side chain-side chain intramolecular hydrogen bonds and calculate the TDP. Our free-energy function has been tested for three different decoy sets. It is better than any other physics-based or knowledge-based potential function in terms of the accuracy in discriminating the native fold from misfolded decoys and the achievement of high Z-scores.

Ligand mapping on protein surfaces by the 3D-RISM theory: toward computational fragment-based drug design.

In line with the recent development of fragment-based drug design, a new computational method for mapping of small ligand molecules on protein surfaces is proposed. The method uses three-dimensional (3D) spatial distribution functions of the atomic sites of the ligand calculated using the molecular theory of solvation, known as the 3D reference interaction site model (3D-RISM) theory, to identify the most probable binding modes of ligand molecules. The 3D-RISM-based method is applied to the binding of several small organic molecules to thermolysin, in order to show its efficiency and accuracy in detecting binding sites. The results demonstrate that our method can reproduce the major binding modes found by X-ray crystallographic studies with sufficient precision. Moreover, the method can successfully identify some binding modes associated with a known inhibitor, which could not be detected by X-ray analysis. The dependence of ligand-binding modes on the ligand concentration, which essentially cannot be treated with other existing computational methods, is also investigated. The results indicate that some binding modes are readily affected by the ligand concentration, whereas others are not significantly altered. In the former case, it is the subtle balance in the binding affinity between the ligand and water that determines the dominant ligand-binding mode.

Nek2 as a novel molecular target for the treatment of breast carcinoma.

We investigated the role of Nek2, a member of the serine-threonine kinase family, in the tumorigenic growth of breast carcinoma. Increased expression of Nek2 was observed in all breast carcinoma cell lines examined (BT20, BT474, Hs578T, MCF7, MDA-MB-231, T47D, and ZR-75-1) by immunoblotting. By treatment with Nek2 short interfering RNA (siRNA), expression of Nek2 was clearly decreased in both estrogen receptor (ER)-positive (MCF7) and ER-negative (MDA-MB-231) breast carcinoma cell lines. Cell growth, colony formation in soft agar, and in vitro invasiveness of these cell lines were substantially suppressed by Nek2 siRNA treatment. In a xenograft nude mouse model with subcutaneous implantation of MCF7 or MDA-MB-231, subcutaneous injection of Nek2 siRNA around the tumor nodules resulted in a reduction of tumor size compared with those of control siRNA injection. Taken together, Nek2 appears to play a pivotal role in tumorigenic growth of breast carcinoma cells, and could be a useful therapeutic molecular target for the treatment of breast carcinoma both in ER-positive and ER-negative cases.

Clinicopathologic study of cholangiocarcinoma with superficial spread.

OBJECTIVE: To review our experience with cholangiocarcinoma with superficial spread, to clarify its clinical features, and to discuss treatment strategies. SUMMARY BACKGROUND DATA: Most of the previous reports on cholangiocarcinoma with superficial spread were case reports. Little is known about this type of cholangiocarcinoma. METHODS: The medical records of 471 patients with cholangiocarcinoma who underwent resection (351 perihilar and 120 distal cancers) were retrospectively reviewed, focusing on superficial spread, which was defined as noninvasive cancer extension of more than 20 mm. RESULTS: Superficial spread was found in 69 (14.6%) of 471 patients, and its length was 54 +/- 19 mm. Histologically, papillary and well differentiated adenocarcinomas were observed more frequently in cholangiocarcinomas with superficial spread (C(+SS)), compared with those without superficial spread (C(-SS)). Histologic indexes showing tumor aggressiveness, including lymphatic, venous, and perineural invasions, were lower in C(+SS), and all factors of tumor staging (pT, pN, and pM) were less advanced in C(+SS) than in C(-SS). Regarding surgical procedure, a combined hepatectomy and pancreatoduodenectomy was indicated in 26 (37.7%) of the 69 patients with C(+SS), but in only 25 (6.2%) of the 402 patients with C(-SS). Positivity of the proximal ductal margin was higher in C(+SS) than in C(-SS) (18.8% vs. 11.9%), although this was not statistically significant. All positive proximal ductal margins in C(+SS) were because of carcinoma in situ, whereas invasive cancer was the main reason for positivity in C(-SS). Survival (excluding 29 in-hospital deaths) was significantly better in the patients with C(+SS) than in those with C(-SS) (5- and 10-year survival rates; 48.8% and 19.6% vs. 26.8% and 16.6%, P = 0.0009). Survival was comparable between the patients with a negative ductal margin and those with a positive margin with carcinoma in situ. On multivariate analysis, the presence or absence of superficial spread was not identified as a prognostic factor. CONCLUSIONS: C(+SS) is associated with less advanced, slower growing tumors and better survival compared with C(-SS). In many cases of C(+SS), the survival does not depend on the complete resection of all the superficial spread but on the stage of the main lesion.