[A Case of Liver Metastasis of Gastric Cancer Successfully Treated with SOX plus Nivolumab].

An 82-year-old, male. He visited his local doctor with a chief complaint of dyspnea on exertion. Anemia was noted, and upper gastrointestinal endoscopy was performed, which revealed an ulcerative lesion in the gastric antrum. A biopsy revealed Group 5, tub2, and HER2 negative, with PD-L1≥5%. cT3N1H1(M1 HEP), cStage ⅣB was diagnosed based on CT scan showing enlarged #8 lymph node and a single liver metastasis in the 2 cm range in S6 of the liver. The patient was deemed unresectable and was started on SOX plus nivolumab therapy. On day 11 after initiation, the patient had Grade 3 diarrhea by CTCAE v5.0, and S-1 was withdrawn for 3 days, but was administered for 2 courses. CT and MRI after chemotherapy showed shrinkage of both the primary tumor and liver metastases; R0 resection was deemed possible, and pyloric gastrectomy, D2 lymph node dissection, and partial hepatic S6 resection were performed. The histological evaluation of response to treatment was Grade 1b, and the patient was in ypStage ⅠA. The patient has been alive without recurrence for 6 months postoperatively while receiving S-1 monotherapy on an outpatient basis.

[Long-Term Survival following Multidisciplinary Therapy for Unresectable Pancreatic Body Cancer].

A 57-year-old man was diagnosed with a tumor in the pancreatic body at a nearby hospital and consulted our hospital. Examinations revealed that carbohydrate antigen 19-9(CA19-9)levels were 1,765.0 U/mL. We confirmed metastatic liver tumors in S4 and S8 of the liver by EOB-MRI. We diagnosed unresectable pancreatic cancer(T3N0M1, cStage Ⅳ)and administered 10 courses of gemcitabine(GEM)plus nab-paclitaxel(nab-PTX)therapy. The main lesion and the lesion in S4 subsequently disappeared, and the lesion in S8 degenerated into a cyst. CA19-9 levels were 113 U/mL. Surgery was determined as the best course of action after normalizing CA19-9 levels. Therefore, we further administered 6 courses of FOLFIRINOX therapy and 4 courses of GEM plus nab-PTX therapy, but CA19-9 was not normalized. We decided that it would be difficult to normalize CA19-9, and thus proceeded with surgery. During the operation, cystic degenerative lesions were found in S8 and peritoneal dissemination was found in the transverse mesentery. Because the ascites cytopathology was negative, it was judged that the peritoneal dissemination was localized. We performed distal pancreatectomy(D2)plus partial hepatectomy(S8)plus peritoneal dissemination resection. On day 52 after surgery, we resumed GEM plus nab-PTX. The patient has survived without any recurrence for 3 years after the initial surgery.

[A Case of Pancreas Neuroendocrine Carcinoma Achieved Long-Term Survival by Carboplatin plus Etoposide Therapy].

A 70-year-old man with the history of diabetes mellitus complained of lower abdominal discomfort. Abdominal ultrasonography revealed a pancreatic mass. Contrast enhanced CT showed a 2.6 cm-enhanced tumor ventral to the pancreatic head. It was diagnosed with a pancreatic neuroendocrine carcinoma(PanNEC-G3)by EUS-FNA. The patient underwent pancreatoduodenectomy with the wedge resection of the portal vein and partial resection of the transverse colon. We administered 6 cycles of adjuvant therapy with CDDP plus CPT-11. With the presentation of lymph node metastases and the local recurrence in the anastomotic site of the transverse colon 15 months after surgery, the patient received carboplatin plus etoposide(CE)therapy. Although local recurrence completely responded to the CE therapy, bone metastases were detected 27 months after surgery. Metastatic lesion did not respond to systemic chemotherapy including gemcitabine plus nab-paclitaxel and nal-IRI plus 5-FU/LV, and the patient eventually died 37 months after the surgery. PanNECs represent for less than 1% of all pancreatic tumor. They are characterized by high malignant potential and short time survival with the reported OS of 8.5 to 21 months. This case served as an important reminder to consider multimodal treatment for PanNEC patients to obtain longer survival.

[A Case of Esophageal Neuroendocrine Carcinoma(NEC)Treated with Collective Treatment].

A 68-year-old man presented to our hospital. An upper gastrointestinal tract endoscopy performed elsewhere revealed an elevated lesion with a circumferential esophageal cancer(identified as small cell carcinoma). Perthe treatment forsmall cell cancer and the standard treatment for esophageal neuroendocrine carcinoma, 7 courses of CBDCA(5mg/m2)plus ETP (100mg/m2)were administered. The lesion shrank and the lymph node swelling disappeared and the patient was deemed to be in partial remission. Nine months later, however, the primary tumor increased in size. A transthoracic subtotal esophagectomy( laparoscope-assisted), 2 area dissection, and gastric tube reconstruction(post-sternal)were performed at 2 years and 10 months afterdiagnosis.

[A Case of Long-Term Survival with Far Advanced Gastric Cancer after Multidisciplinary Treatments, including Conversion Surgery].

An 82-year-old man with Stage Ⅳ advanced gastric cancer and multiple liver metastases was referred to our hospital. Chemotherapy using S-1 was administered, resulting in withdrawal from the usual course because of an adverse event of grade 4 anorexia. GIS and EOB-MRI showed a prominent tumor reduction in both lesions; however, despite this, distal gastrectomy, D2 lymph node dissection, liver biopsy for S3 lesion, partial liver resection for S6 lesion, and cholecystectomy were performed to obtain a therapeutic diagnosis. Pathology revealed that the tumor cells remained in the main liver metastatic lesions. Therapeutic effect was assessed as Grade 2. Although weekly paclitaxel followed by reduced S-1 dosage was introduced after surgery, the recurrent mass was observed in the para-aortic region after 2 years. Subsequently, para-aortic lymph node dissection was performed because no new lesion was detected. More than 10 years have passed without any recurrence since the first surgery. As part of a multidisciplinary treatment for far advanced gastric cancer with multiple liver metastases (Stage Ⅳ), conversion surgery might be considered effective.

Improving the Solid-State Photostability of Furosemide by Its Cocrystal Formation.

The photostability of three types of furosemide (FUR) cocrystal (FUR-caffeine, FUR-urea, and FUR-nicotinamide cocrystals) was studied under irradiation with a D65 fluorescent lamp. The coloration of the FUR-urea pellets was significantly faster than that of the intact FUR, whereas the coloration of FUR-nicotinamide was suppressed compared with that of intact FUR and the other cocrystals. In the case of FUR-urea, the chemical degradation of FUR increased by approximately 6.6% after irradiation for 90 d. On the other hand, FUR-nicotinamide showed better chemical stability, with only 1.3% of FUR degraded, which was significantly lower than the other cocrystals. The FUR-urea pellets showed a UV-Visible absorption spectrum similar to that of intact FUR, while the absorption range of FUR-nicotinamide shifted to a shorter wavelength. The light sensitivity of FUR-nicotinamide was improved because of the much lower emission of the D65 fluorescent lamp in the absorption range of the cocrystal.

[A Resected Case of Rectal Metastasis from Gastric Cancer].

An 82-year-oldwoman previously underwent total gastrectomy for gastric cancer at the age of 75 years. After 7 years of follow-up, a colonoscopy was performedto investigate the cause of constipation, which revealedan irregularity in the rectal submucosa. A colonoscopy-guidedbiopsy showedpoorly differentiatedad enocarcinoma, andthe immunohistochemical staining pattern showedMUC2(-), MUC5AC(+), CDX2(+), andCA1 25(-). FDG-PET showedintense uptake only at the rectum. Thus, laparoscopic high anterior resection was performed. Pathological findings showed that poorly differentiated adenocarcinoma and signet-ring cell carcinoma hadd evelopedmainly in the submucosa. In comparison with the immunohistological features of the previous gastric cancer, the rectal tumor hadsimilar morphological characteristics. The definitive diagnosis was rectal metastasis from gastric cancer. She has remained recurrence-free in the 20 months since this operation.

[HER2-Positive Advanced Gastric Cancer with Para-Aortic Lymph Node Metastases Treated with Conversion Surgery after Chemotherapy-A Case Report].

A 56-year-old woman diagnosed with type 2 gastric cancer and multiple lymph node metastases(T3N3M1[lym], cStage Ⅳ)was treated with chemotherapy using trastuzumab with S-1 plus cisplatin for 6 cycles. The primary lesion showed PR, and lymph node metastases disappeared after the chemotherapy. Because of adverse events, she was administered with 2 additional cycles of trastuzumab with S-1 plus cisplatin and 6 cycles of trastuzumab with capecitabine plus oxaliplatin. However, the primary lesion increased in size. Therefore, she underwent distal gastrectomy and D1+ lymphadenectomy with para-aortic lymph node sampling as a conversion surgery. The pathological diagnosis was T2N0M0, pStage ⅠB, and the primary cancer was Grade 1a owing to the chemotherapeutic effect. She survives without recurrence or postoperative adjuvant therapies 3 years after the surgery.

[A Case of Far-Advanced Esophageal Cancer with Multiple Metastases Showing Long-Term Survival after Chemotherapy].

A 71-year-oldman with voice hoarseness was referredto our hospital for further examination. He was diagnosedwith unresectable Stage Ⅳb esophageal cancer, with direct invasion to the aorta andtrachea andmultiple metastases to the lymph nodes, lungs, and adrenal gland. Because his performance status(PS)was deemedto be favorable, he receivedchemotherapy with docetaxel(DOC), cisplatin, and5 -FU(DCF therapy). After 2 cycles of DCF therapy, the primary lesion was scarred. No malignant lesions were detected in the biopsy performed. No distant metastases were identified on PET-CT. As a subsequent treatment, S-1 plus DOC therapy was administered. Finally, single S-1 administration was continued. The treatment periodwas 14 months. Treatment was concludedbecause a complete response(CR)was maintained. Three years after the conclusion of treatment, CR remains maintained. The overall survival in cases of unresectable advanced esophageal cancer is saidto be 3-10 months, but there are remarkable cases such as this one. If a goodPS is maintained, treatment shouldbe actively considered because CR is possible.

Enhancing Study Motivation and Efficacy among First-year Students Using Minute Papers in the Interdisciplinary Subject of Yakugaku Nyumon.

Active learning in higher education is important for learning efficacy and motivation. Accordingly, lectures that integrate strategies toward active learning, such as minute papers, debates, and collaborative learning, have become widely adopted. Minute papers facilitate communication among both teachers and students, and can be used as a tool for reviewing lectures. In the present study, we examined the effect of using minute papers on learning efficacy and motivation. To enhance the curriculum of the interdisciplinary course Yakugaku Nyumon, which consists of an omnibus lecture series and problem-based learning, minute papers with exercises were provided to applicants. In a follow-up questionnaire, students who used minute papers (S-USE) responded that they had a better understanding of the relationships, ranging from basic to clinical subject matter, than students who did not use such papers (S-NON). Using the Attention, Relevance, Confidence, and Satisfaction (ARCS) model questionnaire to measure study motivation, S-USE scored higher for some questionnaires than S-NON. This finding indicates that minute papers promoted learning motivation among students taking the Yakugaku Nyumon course. In regular examinations, the average score of S-USE was also statistically higher than that of S-NON. These results demonstrate that minute papers possibly encouraged students to actively review the lectures, thereby increasing both learning efficacy and motivation. This study shows that through promoting active, self-learning, minute papers are suitable for improving curricular strategies in subjects that rely on passive learning methods.

Interdisciplinary Subject "Yakugaku Nyumon" for First-year Students Constructed with Lectures and Problem-based Learning.

In 2013, Kobe Pharmaceutical University established "Yakugaku Nyumon", an interdisciplinary course, which consists of omnibus lectures and problem-based learning (PBL) on topics ranging from basic to clinical subjects. The themes of the PBL were original ones; "Study from package inserts of aspirin", which aimed to reinforce the contents of the interdisciplinary lectures, and "Let's think about aspirin derivatives (super-aspirin)", which aimed to engender an interest in studying pharmacy. The PBL featured questions from teachers to help with study and was therefore referred to as "question-led PBL" (Q-PBL). The Q-PBL regarding aspirin derivatives began with preparing answers to the questions for a small group discussion (SGD) as an assignment, followed by a SGD, a presentation, and peer-feedback. From an analysis of the questionnaire survey, it was found that students considered the Q-PBL satisfying and that they had achieved the 4 aims: (1) to increase the motivation to study, (2) to enhance an understanding of the relations and significance of basic and clinical sciences, (3) to comprehend the learning content, and (4) to recognize the importance of communication. The Q-PBL with assignments has two favorable points. One is that the first-year students can challenge difficult and high-level questions when they are given these as assignments. The other is that students, who are unfamiliar with SGD can engage in discussions with other students using the knowledge gained from the assignment. The introduction of omnibus lectures and Q-PBL, along with these improvements in theme, application, and review process, promises increased learning efficacy at the university.

Differences in the rheological properties and mixing compatibility with heparinoid cream of brand name and generic steroidal ointments: The effects of their surfactants.

Most steroidal ointments contain propylene glycol (PG) and surfactants, which improve the solubility of corticosteroids in white petrolatum. Surfactants aid the uniform dispersal of PG within white petrolatum. Since the surfactants used in generic ointments are usually different from those used in brand name ointments, we investigated the effects of surfactants on the rheological properties of three brand name ointments and six equivalent generic ointments. We detected marked differences in hardness, adhesiveness, and spreadability among the ointments. Further examinations of model ointments consisting of white petrolatum, PG, and surfactants revealed that the abovementioned properties, especially hardness and adhesiveness, were markedly affected by the surfactants. Since steroidal ointments are often admixed with moisturizing creams prior to use, we investigated the mixing compatibility of the ointments with heparinoid cream and how this was affected by their surfactants. We found that the ointments containing glyceryl monostearate demonstrated good mixing compatibility, whereas those containing non-ionic surfactants with polyoxyethylene chains exhibited phase separation. These results were also consistent with the findings for the model ointments, which indicates that the mixing compatibility of steroidal ointments with heparinoid cream is determined by the emulsifying capacity of the surfactants in their oily bases.

Prominent efficiency in skin delivery of resveratrol by novel sucrose oleate microemulsion.

OBJECTIVES: To achieve an efficient skin delivery of resveratrol using sucrose fatty acid ester microemulsions and to clarify the mechanism of enhanced penetration. METHODS: Skin delivery of resveratrol using different sucrose fatty acid ester microemulsions was examined in vitro. Vehicle-skin interaction was assessed by applying blank microemulsions to skin. Skin incorporation of microemulsion components was also assessed. KEY FINDINGS: The microemulsion consisting of sucrose oleate (SO), ethanol, isopropyl myristate (IPM) and water (MESO-E) showed a prominent increase in the amount of skin incorporation of resveratrol, which was more than 5-fold higher than those of all microemulsions we previously examined. Using MESO-E, resveratrol was rapidly incorporated into skin and mainly located in the dermis. When applied in the concentration range of 5-55 mm, the amount of skin incorporation of resveratrol increased with the applied concentration up to 30 mm, whereas skin incorporation efficiency was inversely proportional to the concentration. The microemulsion-skin interaction seemed to be involved in the enhanced skin delivery process of resveratrol by MESO-E. Stratum corneum modification due to the penetration of IPM, ethanol and SO is also involved in this interaction. CONCLUSIONS: MESO-E would be a promising vehicle for the efficient skin delivery of resveratrol, especially when applied at a low concentration.

Microemulsion Using Polyoxyethylene Sorbitan Trioleate and its Usage for Skin Delivery of Resveratrol to Protect Skin against UV-Induced Damage.

We examined the phase behavior of various polyoxyethylene sorbitan fatty acid ester (polysorbates)/ethanol/isopropyl myristate (IPM)/150 mM NaCl solution (NaClaq) systems in order to prepare a microemulsion containing a low ratio of ethanol, which is more suitable for in vivo application. Using polyoxyethylene sorbitan trioleate (Tween 85), which has a large lipophilic moiety, as a surfactant component, single-phase domain of the phase diagram was the largest of all the polysorbates examined, and in particular a large oil-rich single-phase domain was obtained. When the ratio of Tween 85 to ethanol was changed from 1 : 1 to 3 : 1, the oil-rich single-phase domain further expanded, which led to a reduced ethanol concentration in the preparation. Thus, we determined the composition of the microemulsion to be Tween 85 : ethanol : IPM : NaClaq=30 : 10 : 53 : 7, and used it for skin delivery of resveratrol. Microemulsion gel was also prepared by adding 6.5% Aerosil) 200 into the microemulsion for ease of topical application. When applied with each vehicle, delivery of resveratrol into guinea pig skin in vitro was significantly enhanced compared with that by IPM, and resveratrol incorporated into the skin by microemulsion gel decreased lipid peroxidation to 29.5% compared with that of the control. Pretreatment of guinea pig dorsal skin with the microemulsion gel containing resveratrol almost completely prevented UV-B-induced erythema formation in vivo. These findings demonstrate that the microemulsion using Tween 85 containing a minimal concentration of ethanol enhanced the skin delivery of resveratrol and the incorporated resveratrol exhibited a protective effect against UV-induced oxidative damage.

Effects of mixing procedure itself on the structure, viscosity, and spreadability of white petrolatum and salicylic acid ointment and the skin permeation of salicylic acid.

White petrolatum is a mixture of solid and liquid hydrocarbons and its structure can be affected by shear stress. Thus, it might also induce changes in its rheological properties. In this study, we used polarization microscopy to investigate how different mixing methods affect the structure of white petrolatum. We used two different mixing methods, mixing using a rotation/revolution mixer and mixing using an ointment slab and an ointment spatula. The extent of the fragmentation and dispersal of the solid portion of white petrolatum depended on the mixing conditions. Next, we examined the changes in the structure of a salicylic acid ointment, in which white petrolatum was used as a base, induced by mixing and found that the salicylic acid solids within the ointment were also dispersed. In addition to these structural changes, the viscosity and thixotropic behavior of both test substances also decreased in a mixing condition-dependent manner. The reductions in these parameters were most marked after mixing with a rotation/revolution mixer, and similar results were obtained for spreadability. We also investigated the effects of mixing procedure on the skin accumulation and permeation of salicylic acid. They were increased by approximately three-fold after mixing. Little difference in skin accumulation or permeation was detected between the two mixing methods. These findings indicate that mixing procedures themselves affect the utility and physiological effects of white petrolatum-based ointments. Therefore, these effects should be considered when mixing is required for the clinical use of petrolatum-based ointments.

Efficient delivery and distribution in skin of chlorogenic acid and resveratrol induced by microemulsion using sucrose laurate.

To achieve efficient skin delivery of polyphenols, we prepared a novel oil-in-water (o/w)-type microemulsion (MESL) using sucrose laurate as a surfactant and ethanol, isopropyl myristate and water as other components. We examined its usefulness by in vitro studies on skin delivery of chlorogenic acid and resveratrol as hydrophilic and hydrophobic polyphenols using Yucatan micropig skin, and also examined the difference in the distribution of these polyphenols in skin. MESL significantly improved skin incorporation of these polyphenols at all time points examined (6, 20, 40 h) in the epidermis and at 20 and 40 h in the dermis, compared with the microemulsion using Tween 80 as a surfactant component (MEK), although the solubilization capacity of MESL was lower than that of MEK. Using MESL, the incorporation amount in the dermis of each polyphenol increased with time, while the amount in the epidermis was almost constant during the time examined. Incorporation efficiencies into skin of chlorogenic acid and resveratrol induced by MESL at 40 h after application were about 6-fold and 19-fold higher in the epidermis and 3.5-fold and 15-fold higher in the dermis, respectively, than those by MEK. The increase was more prominent for resveratrol. Hydrophilic chlorogenic acid was distributed slightly more in the epidermis, while hydrophobic and smaller-molecular-weight resveratrol was mainly distributed in the dermis. These findings suggest that MESL could be a promising vehicle for the efficient skin delivery of chlorogenic acid and resveratrol, especially for resveratrol to the dermis.

Bile salt-stimulated phospholipid efflux mediated by ABCB4 localized in nonraft membranes.

ABCB4 is necessary for the secretion of phospholipids from hepatocytes into bile and for the protection of cell membranes against bile salts. Lipid rafts are plasma membrane microdomains containing high contents of cholesterol and sphingolipids, which are separated by Triton X-100 extraction or OptiPrep gradient centrifugation. In this study, we investigated the relationship between the function of ABCB4 and lipid rafts using mouse canalicular membranes and HEK293 cells stably expressing ABCB4. ABCB4 and ABCB1 were mainly distributed in nonraft membranes. The expression of ABCB4, but not ABCB1, led to significant increases in the phosphatidylcholine (PC), phosphatidylethanolamine (PE), and sphingomyelin (SM) contents in nonraft membranes and further enrichment of SM and cholesterol in raft membranes. The ABCB4-mediated efflux of PC, PE, and SM was significantly stimulated by taurocholate, while the efflux of PE and SM was much less than that of PC. This ABCB4-mediated efflux was completely abolished by BODIPY-verapamil, which hardly partitioned into raft membranes. In addition, ABCB1 and ABCB4 mediated the efflux of rhodamine 123 and rhodamine 6G from nonraft membranes, which was not affected by taurocholate. We conclude that ABCB4 located in nonrafts, but not in rafts, is predominantly involved in the efflux of phospholipids and other substrates.

Distribution of polyphenols and a surfactant component in skin during Aerosol OT microemulsion-enhanced intradermal delivery.

As for most other polyphenols, intradermal delivery of curcumin and resveratrol is limited; however, it was significantly improved by a microemulsion using Aerosol OT (Aerosol OT microemulsion) and Tween 80 (Tween 80 microemulsion) as surfactants. Aerosol OT microemulsion was more effective and the incorporation ratio of these polyphenols into skin by Aerosol OT microemulsion was five-fold or ten-fold that by Tween 80 microemulsion. To clarify the mechanism of the enhancement we examined the distribution of these polyphenols and the surfactant component, Aerosol OT, using excised guinea pig skin and Yucatan micropig (YMP) skin. During permeation, polyphenols distributed deep in the skin. In particular, a small molecule, resveratrol, was mainly present in the dermis in YMP skin. Aerosol OT also distributed deep in the skin. These findings suggest the possible involvement of the interaction of surfactant molecules with skin components in the enhanced delivery process of polyphenols. The distribution ratio between the dermis and epidermis of the polyphenols, including quercetin, in the presence of Aerosol OT microemulsion decreased with the increase of molecular weight in YMP skin, suggesting the possibility that distribution to the dermis is regulated by the molecular size.

Specific and sensitive enzymatic measurement of sphingomyelin in cultured cells.

Sphingomyelin (SM) is the most abundant sphingolipid in mammalian cell membranes and plays multiple physiological roles. In this study, we improved the sensitivity of the enzymatic measurement of SM and validated its specificity and accuracy. The enzymatic reaction sequence of the method involves the hydrolysis of SM by sphingomyelinase, dephosphorylation of phosphorylcholine, oxidation of choline, and reaction of hydrogen peroxide with Amplex Red. The calibration curve was shown to be quadratic and linear at low (0-10 µM) and high (10-100 µM) concentrations, respectively, and the detection limit was 0.5 µM (5 pmol in the reaction mixture), which was more sensitive than all other SM assays reported previously. This SM measurement using Triton X-100 detected only SM, but not other choline-containing phospholipids, sphingosylphosphocholine, phosphatidylcholine, and lysophosphatidylcholine, and quantified SM regardless of the length and double bonds of the acyl chain. By using this method, we demonstrated that an increase in the density of HEK293 cells was accompanied by an elevation in the cellular content of SM, and that the treatment of HEK293 cells with tumor necrosis factor α significantly decreased the SM content. This specific and sensitive method for measuring SM will be helpful in studying various cellular processes.

Enzymatic measurement of phosphatidylserine in cultured cells.

Phosphatidylserine (PS) is a quantitatively minor membrane phospholipid involved in diverse cellular functions. In this study, we developed a new fluorometric method for measuring PS using combinations of specific enzymes and Amplex Red. The calibration curve for PS measurement was linear and hyperbolic at low (0-50 µM) and high (50-1000 µM) concentrations, respectively, and the detection limit was 5 µM (50 pmol in the reaction mixture). This assay quantified PS regardless of the chain length and the number of double bonds. We applied this new method to the determination of PS content in HEK293 cells, which was validated by a recovery study and comparison with TLC-phosphorus assay. We showed that the PS content was high in sparse cells. The overexpression of PS synthase 1 elevated not only the cellular PS content but also the phosphatidylcholine (PC) and phosphatidylethanolamine (PE) contents, suggesting the conversion of PS into PE and the enhancement of PC production. This new assay for PS measurement is simple, specific, sensitive, and high throughput, and it will be useful to clarify the metabolism and biological functions of PS.