Gastric Invasive Micropapillary Carcinoma with Intestinal Phenotypes Harboring a TP53 R175H Mutation.

We report a case of gastric invasive micropapillary carcinoma (IMPC) in an 86-year-old female patient. She was admitted to our hospital with a chief complaint of bloody emesis. Upper gastrointestinal endoscopy found a gastric adenocarcinoma at the antrum. The biopsy specimens showed moderately differentiated adenocarcinoma with invasive small tumor nests. Distal gastrectomy with systematic lymph node dissection demonstrated that the tumor had IMPC through a pathological examination. Despite the depth of tumor invasion (the submucosa), extensive lymph node metastases were observed. Anti-D2-40 immunostaining revealed numerous infiltrating tumor cell nests in the lymphatic vessels, which could explain subsequent multiple lymph node metastases. The adenocarcinoma showed intestinal phenotypes by several immunohistochemical studies. One of these antibodies (CD10) clearly demonstrated the inverted apical-basal (inside-out) pattern of IMPC, whereas it showed an ordinary pattern in intestinal metaplasia adjacent to the tumor. Furthermore, genetic analysis by direct sequencing revealed a point mutation in the exon 5 of TP53 in the tumor. The mutation presumably harbors a missense mutation from Arg to His at the codon 175 (R175H). R175H has been previously described as a 'gain-of-function' mutation with a high invasive or metastatic potential in several types of cancers. In summary, this is one of the first reported cases of gastric IMPC with intestinal phenotypes harboring a TP53 R175H mutation in the literature.

Two-layer challenge test as an assessment to predict islet graft function.

BACKGROUND/AIMS: To investigate graft viability assessment before transplantation using 31P-Nuclear Magnetic Resonance (NMR) spectroscopy combining a two-layer old storage method (TLM). METHODOLOGY: Rat pancreases were divided into three groups and respectively subjected to 0 (group 1), and 30 minutes (group 2) of warm ischemia (WI) before procurement. Pancreases were digested and pancreatic digest tissues were preserved for 3 h using TLM. 31P-NMR spectroscopy was used to measure ATP levels of digest tissue. After TLM, the ratio of beta-adenosine triphosphate to phosphate monoester (betaATP/PME) obtained by 31P-NMR spectroscopy was evaluated. Isolated islets were assessed for yield and in vivo function separately using nude mice. RESULTS: The betaATP/PME ratios were 0.11 +/- 0.04, and 0.03 +/- 0.01 in groups 1 and 2, respectively (P < 0.05). Islet yields (IEQ/pancreas) were significantly less in group 3 (P < 0.05) and the cure rate after transplantation of 200 islets to athymic nude mice were 100% (7/7), and 0% (0/7) in groups 1 and 2, respectively. We regard groups 1 as viable group and group 2 as non-viable group. The viable groups and the non-viable group were clearly distinguished by betaATP/PME ratios. CONCLUSION: 31P-NMR spectroscopy combining TLM provided an objective and rapid means to assess severity of islet graft damage prior to transplantation in the rat model.

Prevention of intimal hyperplasia employing the cavitary two-layer method in allogeneic rat heart transplantation.

BACKGROUND: The development of graft arteriosclerosis is a significant contributor to chronic rejection in organ transplant recipients. The purpose of the present study was to establish whether or not the cavitary two-layer method can prevent graft arteriosclerosis after rat heart transplantation. METHODS: F-344 rats served as donors to Lewis recipients. Grafts in the control group (group C) were immediately allotransplanted without preservation. Grafts were also transplanted after cold preservation for 3 h in University of Wisconsin solution (group UW), or employing the cavitary two-layer (CTL) method (group TL). In another group (group W), grafts were subjected to 15-min warm ischemia and then transplanted. Grafts damaged by ischemia were also transplanted after preservation for 3 h using CTL (group WTL). We measured intimal thickening (IT) before transplantation and at 30 and 60 d post-transplant and also assessed the expression of heat shock proteins (HSPs). RESULTS: At 60 d post-transplant, IT in group WTL was significantly lower than in group W (0.30 ± 0.03 versus 0.45 ± 0.04, respectively). In contrast, no significant changes were observed in the cold storage groups. Expression of HSPs 60 and 70 at 60 d in group WTL (25.40% ± 1.64% and 35.96% ± 2.65%, respectively) was reduced compared with group W (46.07% ± 5.84% and 55.11% ± 1.54%, respectively). CONCLUSIONS: CTL reduces IT induced by warm ischemia in rat heart transplantation, and allows the maintenance of low HSP 60 and 70 expression.

Histopathological predictors of regional lymph node metastasis at the invasive front in early colorectal cancer.

AIMS: In early colorectal cancer (ECC), prediction of lymph node (LN) metastasis is vital for the decision of additional surgical treatment after endoscopic mucosal/submucosal resection. The aim of this study was to determine the relationship between LN metastasis and comprehensive histopathological findings including the cancer microenvironment in ECC. METHODS AND RESULTS: Using 111 ECC cases, including 36 cases with LN metastasis, histopathological observations and immunohistochemistry for lymphatic vessel endothelial hyaluronan receptor-1 (LYVE-1), von Willebrand factor, matrix metalloproteinase-7 (MMP-7), CXC chemokine ligand-12 (CXCL12) and angiopoietin-like-4 (ANGPTL4) were conducted. Relationships between LN metastasis and growth pattern, status of muscularis mucosae, depth of cancer invasion, overall histopathological type, histopathological type at the invasive front, tumour budding, neutrophil infiltration in cancer cells (NIC), fibrotic cancer-stroma type, Crohn's-like lymphoid reaction, microscopic abscess formation and lymphatic invasion were determined. In addition, the expression of MMP-7, CXCL12 and ANGPTL4 in cancer cells at the invasive front were also considered in the context of LN metastasis. By multivariate analysis, lymphatic invasion, NIC and MMP-7 expression at the invasive front were independent predictors of LN metastasis. CONCLUSIONS: LN metastasis is regulated not only by the characteristics of cancer cells but also by microenvironmental factors of lymphatics and neutrophils, especially at the invasive front.

Oxygenation of the portal vein by intraperitoneal administration of oxygenated perfluorochemical improves the engraftment and function of intraportally transplanted islets.

OBJECTIVES: One of the major obstacles for successful intraportal islet transplantation (IPIT) is early graft loss due to hypoxia. We therefore examined the effect of intraperitoneal oxygenated perfluorochemical (PFC) on oxygenation of the portal vein with respect to islet engraftment and function after IPIT in a rat model. METHODS: First, we measured the oxygen tension and saturation in the portal vein of Lewis rats before and after intraperitoneal injection of oxygenated PFC. Second, blood glucose levels, glucose tolerance, and the number of surviving islets were measured after IPIT with oxygenated PFC (group 1), with PFC saturated by nitrogen (group 2), and without any PFC (control). RESULTS: Both oxygen tension and saturation in the portal vein significantly increased after injection of oxygenated PFC. In IPIT, the functional success rate in group 1 was 83.3%, compared with 16.7% in group 2 and 16.7% in the control. On the 28th posttransplantation day, the number of engrafted islets in the liver in group 1 (12.8 [SD, 3.3]) was significantly higher than that in group 2 (4.7 [SD, 3.0]) and in the control group (6.5 [SD, 3.3]). CONCLUSIONS: We clearly demonstrated the effect of intraperitoneal oxygenated PFC on oxygenation of the portal vein, resulting in better IPIT outcomes.

Evaluation of tissue blood flow of the gastric tube after vessel anastomosis for esophageal reconstruction.

OBJECTIVES AND METHODS: Impaired blood flow of the upper end of the gastric tube is one of the major causes of anastomotic leak following esophageal reconstruction after esophagectomy for cancer. We applied an additional microvascular anastomosis procedure--the supercharging technique--to improve blood flow. We investigated blood flow improvement in 15 patients who underwent the supercharging technique after total excision of the thoracic esophagus and gastric tube reconstruction through the posterior mediastinal route from August 2003 to March 2005. RESULTS: Tissue blood flow was measured with laser Doppler flowmetry during surgery and was improved after microvascular anastomosis. Patency and blood flow of anastomosed arteries were evaluated with computed tomography and ultrasonography, respectively. Patency and stable blood flow of anastomosed arteries were confirmed more than 1 month after surgery. Therefore, microvascular anastomosis improved the tissue blood flow of the upper end of the gastric tube. Long-term blood flow improvement was confirmed, which suggests that microvascular anastomosis contributes to reducing the risk of anastomotic leak.

Islet transplantation using donors after cardiac death: report of the Japan Islet Transplantation Registry.

BACKGROUND: This report summarizes outcomes of islet transplantation employing donors after cardiac death (DCD) between 2004 and 2007 as reported to the Japan Islet Transplantation Registry. METHOD: Sixty-five islet isolations were performed for 34 transplantations in 18 patients with insulin-dependent diabetes mellitus, including two patients who had prior kidney transplantation. All but one donor (64/65) was DCD at the time of harvesting. RESULTS: Factors influencing criteria for islet release included duration of low blood pressure of the donor, cold ischemic time, and usage of Kyoto solution for preservation. Multivariate analysis selected usage of Kyoto solution as most important. Of the 18 recipients, 8, 4, and 6 recipients received 1, 2, and 3 islet infusions, respectively. Overall graft survival defined as C-peptide level more than or equal to 0.3 ng/mL was 76.5%, 47.1%, and 33.6% at 1, 2, and 3 years, respectively, whereas corresponding graft survival after multiple transplantations was 100%, 80.0%, and 57.1%, respectively. All recipients remained free of severe hypoglycemia while three achieved insulin independence for 14, 79, and 215 days. HbA1c levels and requirement of exogenous insulin were significantly improved in all patients. CONCLUSION: Islet transplantation employing DCD can ameliorate severe hypoglycemic episodes, significantly improve HbA1c levels, sustain significant levels of C-peptide, and achieve insulin independence after multiple transplantations. Thus, DCD can be an important resource for islet transplantation if used under strict releasing criteria and in multiple transplantations, particularly in countries where heart-beating donors are not readily available.

Mucinous cystic neoplasm of the pancreas presenting with hemosuccus pancreaticus: report of a case.

Hemosuccus pancreaticus (HP) is mostly induced by a ruptured pseudoaneurysm or hemorrhage from a pseudocyst in chronic pancreatitis. We herein report a rare case with HP induced by tumor hemorrhage. The present patient is a 71-year-old woman referred to us with a diagnosis of severe progressive anemia. Endoscopy revealed hemorrhage from the papilla of Vater. Computed tomography showed a multilocular cystic tumor in the tail of the pancreas. The patient underwent a distal pancreatectomy. The histopathological diagnosis was carcinoma in mucinous cystadenoma. No cancer infiltration into the pancreatic duct was detected. Pancreatography of the resected specimen demonstrated an overt communication between the main pancreatic duct and the cystic cavity of the tumor, which was not demonstrated preoperatively by endoscopic retrograde pancreatography. Although the cause of HP is mainly acute or chronic pancreatitis, we should bear in mind that a pancreatic tumor may be a possible cause of HP and that, as such, prompt and proper treatment is mandatory.

Effect of oxygenated perfluorocarbon on isolated islets during transportation.

BACKGROUND: Previous studies demonstrated the efficacy of the two-layer method (TLM) using oxygenated perfluorochemicals (PFC) for pancreas preservation. The current study investigated the effect of oxygenated PFC on isolated islets during transportation. MATERIALS AND METHODS: Purified rat islets were stored in an airtight conical tube for 24h in RPMI culture medium at 22 degrees C or University of Wisconsin solution (UW) at 4 degrees C, either with or without oxygenated PFC. After storage, the islets were assessed for in vitro viability by static incubation (SI), FDA/PI staining, and energy status (ATP, energy charge, and ADP/ATP ratio) and for in vivo viability by a transplantation study. RESULTS: UW at 4 degrees C and RPMI medium at 22 degrees C maintained islet quality almost equally in both in vitro and in vivo assessments. The ATP levels and energy status in the groups with PFC were significantly lower than those without PFC. The groups with PFC showed a significantly higher ADP/ATP ratio than those without PFC. In the transplantation study, blood glucose levels and AUC in the UW+PFC group were significantly higher than those in UW group. CONCLUSIONS: UW at 4 degrees C and RPMI medium at 22 degrees C maintained islet quality equally under the conditions for islet transportation. The addition of oxygenated PFC, while advantageous for pancreas preservation, is not useful for islet transportation.

Clinical reappraisal of total pancreatectomy for pancreatic disease.

BACKGROUND/AIMS: In this study, it was reappraised the outcomes of total pancreatectomy (TP), retrospectively analyzing the safety of the procedures and factors associated with long-term survival. METHODOLOGY: Thirty-six consecutive patients underwent TP for pancreas disease at Kobe University Hospital. The outcomes of TP were evaluated, analyzing operation-related results (mortality, morbidity, survival and long-term outcomes) and oncological aspects. RESULTS: Postoperative morbidity was 39% (14/36) and severe complications were anastomotic leakage (n=3) and liver necrosis (n=1). In benign disease, 5-year survival was 50%, while 5-year survival in malignant disease was 22%. Postoperative glycosylated hemoglobin A1c (HbA1c) level was 7.8 +/- 1.2% at 6 months and 7.8 +/- 1.5% at 12 months after TP, respectively. CONCLUSION: TP is safely performed and the treatment option for selectively limited pancreatic cancer and intraductal papillary mucinous neoplasm of the pancreas (IPMN), when the patient condition permits and offers a chance of cure, although careful long-term medical care and follow-up are essential.

[Successful chemoradiation therapy for local control of rectal cancer with multiple bone metastases--a case report].

A 78-year-old man was admitted to our institute with the symptom of melena. The patient was diagnosed as having advanced rectal cancer (T4N2M1) with multiple bone metastases. Chemoradiation therapy was chosen for the local control because our proposal of colostomy was rejected. Concurrent chemoradiation therapy [46 Gy/23 Fr+tegafur/uraci (l UFT 400 mg/m2)/calcium folinate (Leucovorin: LV 75 mg/body)] resulted in a good partial response and the patient became asymptomatic. UFT/LV were administrated and most of the bone metastases were diminished. After 3 years of disease remission with good quality of life, local tumor recurred with the symptoms of melena and bowel obstruction. Colostomy and additional radiotherapy were performed for the palliation. He died after 4 years from the initial treatment. In advanced rectal cancer with distant metastases, chemoradiation therapy for local control plus systemic chemotherapy could be an alternative to improve quality of life.

Enhancement of anti-tumor immunity by high levels of Th1 and Th17 with a combination of dendritic cell fusion hybrids and regulatory T cell depletion in pancreatic cancer.

Regulatory T cells (Tregs) play an important role in immunological self-tolerance and protect the host from autoimmune disease. However, in cancer immunity, Tregs might block anti-tumor immune responses. Therefore, the depletion of Tregs using a specific agent that suppresses its function or population, such as an anti-CD25 antibody, could promote anti-tumor immune responses. In the present study, a cytotoxicity assay, enzyme-linked immunosorbent spot (ELISPOT) assay and measuring cytokine secretion, were used to study the efficacy of Treg depletion by anti-CD25 antibody added to a dendritic cell/tumor cell (DC/TC) fusion hybrid vaccine in a murine pancreatic cancer model. All the mice treated with the combined therapy of fusion hybrid vaccine and Treg depletion rejected tumor growth in a challenging test, although the rejection rate was 20% both for mice that received the fusion hybrids alone or Treg depletion alone. In addition, combined therapy showed a significantly improved survival in comparison to other treatment or control groups. The NK cell activity for DC/TC fusion + Treg depletion was significantly higher than that for the other treatment groups. Cytotoxic T lymphocyte (CTL) activity for DC/TC could potentially be enhanced by the addition of Treg depletion therapy. The treatments including DC/TC fusion induced IFN-gamma secreting effector cells in ELISPOT assays. Furthermore, a cytometric beads array assay used to measure cytokine secretion showed that DC/TC fusion + Treg depletion stimulated the highest levels of IFN-gamma Th1/Th2 ratios and Th17. These results demonstrate that Treg depletion combined with DC/TC fusion hybrid vaccine enhanced the efficacy of immunotherapy in pancreatic cancer by activating CTLs and NK cells.

Experimental comparison of the stapled intestinal anastomotic techniques.

Various techniques of stapled intestinal anastomoses are performed in gastroenterological surgery. Little is known about which technique is optimal. The intestines of a domestic pig were used in this study. Stapled intestinal anastomoses of three types-functional end-to-end anastomosis (FETEA), stapled side-to-end anastomosis (STEA), and stapled end-to-end anastomosis (EEA)-were constructed using pig intestines. The times for constructing anastomoses, length of the completed anastomosed intestine, strength of anastomoses, and bursting locations were measured and recorded on each group. The times required to construct FETEAs (60 S.D. 1.4 sec) were significantly less than those required for STEAs (191.5 S.D. 46.4 sec) and EEAs (274.5 S.D. 54.5 sec). The mean lengths of the completed anastomosed intestine were significantly different for FETEAs (89 S.D. 8.2 mm), STEAs (135 S.D. 6.1 mm), and EEAs (156 S.D. 6.5 mm). The bursting pressures were not significantly different among the three groups. FETEAs are superior in terms of requiring less surgical time. EEAs are superior in terms of the length of anastomosed intestines. In conclusion, anastomotic techniques should be selected properly in consideration of these features.

Mesenchymal stem cells suppress B-cell terminal differentiation.

OBJECTIVE: Mesenchymal stem cells (MSCs) have been shown to possess immunomodulatory properties on a diverse array of immune cell lineages. However, their effect on B lymphocytes remains unclear. We investigated the effect of MSCs on B-cell modulation with a special emphasis on gene regulation mediated by MSC humoral factors. MATERIALS AND METHODS: MSCs were isolated from C57BL/6 bone marrow and expanded in culture. Splenic B cells were purified using anti-CD43 antibody and immunomagnetic beads. B cells and MSCs were cocultured in separate compartments in a transwell system. For B-cell stimulation, lipopolysaccharide was used in vitro and T-dependent and T-independent antigens were used in vivo. RESULTS: In MSC cocultures, lipopolysaccharide-stimulated B-cell proliferation was suppressed, CD138(+) cell percentage decreased, and the number of apoptotic CD138(+) cells decreased. In the B/MSC coculture, the IgM(+) cell percentage was higher and the IgM amount released in the medium was lower than in the control. The B-lymphocyte-induced maturation protein-1 messenger RNA expression in the coculture was suppressed throughout the 3-day culture period. Conditioned media derived from MSC cultures prevented terminal differentiation of B cells in vitro and significantly suppressed the antigen-specific immunoglobulin M and immunoglobulin G1 secretion in mice immunized with T-cell-independent as well as T-cell-dependent antigens in vivo. CONCLUSION: Results indicate that humoral factor(s) released by MSCs exert a suppressive effect on the B-cell terminal differentiation. Suppression may be mediated through inhibition of B-lymphocyte-induced maturation protein-1 expression, but the nature of the factor(s) is yet to be determined.

Utility of the new Japanese severity score and indications for special therapies in acute pancreatitis.

BACKGROUND: The Japanese severity score (JSS) for acute pancreatitis was revised in 2008. As special therapies for severe acute pancreatitis (SAP), continuous regional arterial infusion of protease inhibitor and antibiotics (CRAI) and enteral nutrition (EN) are now utilized in Japan. We investigated the usefulness of the new JSS and the indications for CRAI and EN based on the new JSS. METHODS: We assessed the new JSS in 138 patients with SAP according to the previous Japanese criteria. Usefulness of the new JSS for the prediction of mortality rates was compared with conventional scoring systems by receiver-operator characteristic curve analysis. We analyzed the relationship between the new JSS and prognosis in patients with and without CRAI and EN, respectively. RESULTS: Forty-five patients (33%) were assessed as having mild acute pancreatitis, and 93 patients (67%) were assessed as having SAP. Their mortality rates were 7 and 40%, respectively. The area under the curve for the prediction of mortality rates with the new JSS was 0.822 and was the highest among conventional scoring systems. In patients with new JSS >or= 6, the mortality rate was lower in patients with CRAI than in patients without CRAI (P = 0.129). In patients with new JSS >or= 4, the mortality rate was lower in patients with EN than in patients without EN (P = 0.016). CONCLUSIONS: The new JSS is useful and easier to use for the prediction of prognosis compared to the conventional scoring systems. EN was effective in reducing the mortality rate in patients with a new JSS >or= 4.

Impact of internal biliary drainage after pancreaticoduodenectomy.

BACKGROUND: Bile acid has an important role in protecting immune systems related to gut-associated lymphoid tissue. This study was designed to evaluate the effects of internal biliary drainage after a pancreaticoduodenectomy (PD) on postoperative nutrition and complications in a randomized study. METHODS: The authors compared the morbidity, mortality, and postoperative nutritional status of 46 patients who had a hepaticojejunostomy (HJ) with a stented external biliary drainage (group E) or with a non-stented internal biliary drainage (group I) after a PD. RESULTS: Systemic infection was recognized in four patients in group E, while no patients in group I. Transthyretin at postoperative 28 days in group I was 15.6 +/- 6.2, higher than that in group E. Retinol-binding protein at postoperative 28 days in group I was 2.6 +/- 1.0 and also higher than that in group E. CONCLUSION: HJ with no-stented internal biliary drainage was not associated with systemic infections and mortality, but showed the possibility of improving nutritional status.

Identification of sentinel lymph node location based on body surface landmarks in early breast cancer patients.

BACKGROUND: It would be extremely useful if the location of the sentinel lymph node in breast cancer could be identified based on body surface landmarks. However, the identification of the sentinel node location by using surface landmarks in many reports is based on empirical methodologies. METHODS: We studied the distribution of the sentinel node location in 70 breast cancer patients based on the lateral line of the major pectoral muscle, the axillary skin fold that divides the trunk and the upper arm, and the nipple of the breast. RESULTS: The location of the sentinel node could be predicted using an ellipse with a semi-major axis of 2.8 cm and a semi-minor axis of 2.2 cm with a probability of 95% for a patient with the mean body size. CONCLUSION: Our data demonstrate that the location of the sentinel nodes can be predicted within a narrow area based on body landmarks.

Prognostic value of matrix Gla protein in breast cancer.

To assess the prognostic value of matrix Gla protein (MGP) expression in cases of breast cancer, 9 samples from patients diagnosed with breast cancer who were followed up for more than 10 years were microdissected and then analyzed using Affymetrix U133 Plus 2.0 Arrays. Genes that exhibited significant differences in expression between patients with a good prognosis and those with a poor prognosis were identified. The MGP gene was among the genes up-regulated in cases where the prognosis was poor, indicating that the mRNA levels of MGP are a potential prognostic indicator of breast cancer. However, immunohistostaining of breast tissue microarrays (n=207) did not reveal a correlation between the protein expression of MGP and overall survival, neither was there a correlation between the protein expression of MGP and ER status or bone metastasis. In breast cancer cases, the mRNA level of MGP may be a marker indicating poor prognosis; however, protein expression determined by immunohistostaining is not.

Resection of gallbladder cancer with hepatic metastasis after chemotherapy with gemcitabine.

A 69-year-old man diagnosed as having gallbladder cancer with liver invasion and metastasis to Couinaud's hepatic segment 8 (S8) was referred to our hospital. Because of the presence of liver metastasis, gemcitabine administration was chosen. Although gemcitabine was effective for the liver metastasis, his serum carcinoembryonic antigen (CEA) level had gradually increased after 12 cycles of gemcitabine administration. There was no distant metastasis other than the liver metastasis (manageable with gemcitabine) on detailed radiological examination. Therefore, we performed surgery for the primary lesion, after obtaining informed consent. Pathological examination demonstrated viable cancer cells with necrosis and fibrosis in the gallbladder, and fibrosis without viable cancer cells in the induration in liver S8. Gemcitabine was re-administered as postoperative adjuvant chemotherapy. Twenty months after the surgery, there was no sign of recurrence. In selected patients, gemcitabine treatment may be effective against gallbladder cancer with metastasis.