Intrahepatic cholangiocarcinoma in a patient with Wilson's disease: a case report

The incidence of hepatobiliary malignancies, and especially intrahepatic cholangiocarcinoma (ICC), for patients with Wilson’s disease (WD), is very low, even for cirrhotic patients. A 44-year-old male was admitted to our department for treatment of a liver tumor. He was diagnosed with WD at the age of 15. According to radiological findings, his liver tumor was a suspected hepatocellular carcinoma (HCC) or a combined hepatocellular and cholangiocellular carcinoma. A partial resection of liver segments 8 (S8) and 5 (S5) was subsequently performed due to the intraoperative suspicion of intrahepatic metastasis at the surface of S5. Postoperative histology revealed that the resected portion of S8 contained an ICC; the removed S5 portion comprised a regenerative nodule with hemosiderosis. To date, the patient has survived without tumor recurrence for more than 44 months following surgery. A survey of the literature, inclusive of case reports, would suggest that surgical resection is the primary course of action for a WD patient with ICC, if liver function can be preserved and curative resection performed.

Incidence and risk factors of postoperative delirium in elderly patients who underwent laparoscopic surgery for colorectal cancer

BACKGROUND

The reported incidence of postoperative delirium (POD) in elderly patients ranges from 6 to 53 %. Several preoperative and operative factors have been reported as risk factors of POD.

AIM

The aim of this study was to determine the incidence of and risk factors for POD in patients with colorectal cancer who had undergone laparoscopic colorectal resection.

METHODS

A total of 311 consecutive patients aged 75 years and older who underwent laparoscopic surgery for colorectal cancer at our department from January 2008 to December 2013 were classified as delirious group (n = 44) and nondelirious group (n = 267). Short-term outcomes and risk factors for POD were analyzed.

RESULTS

POD was diagnosed in 14.1 % of elderly patients with colorectal cancer. Univariate analysis showed that older age, high American Society of Anesthesiology (ASA) score, performance status >2, low prognostic nutrition index (PNI), past history of delirium or dementia, operative approach, Organ/Space SSI, and cardiac or pulmonary disease were significantly associated with POD. Multivariate logistic regression analysis identified older age, past history of delirium or dementia, operative approach, and Organ/Space SSI as four independent risk factors for POD.

CONCLUSIONS

Our results suggest that the risk of POD is associated with older age, past history of delirium or dementia, operative approach, Organ/Space SSI.

Single-incision totally extraperitoneal inguinal hernia repair as a teaching procedure: one center's experience of more than 300 procedures

PURPOSE

To evaluate resident doctors' proficiency in performing single-incision laparoscopic surgery for totally extraperitoneal inguinal hernia repair (SILS-TEP), and assess patient outcomes by comparing procedures performed by resident surgeons vs. those performed by staff surgeons.

METHODS

We analyzed retrospectively 301 patients who underwent SILS-TEP between January 2011 and May 2015 at Osaka Police Hospital.

RESULTS

The mean operative times for unilateral and bilateral hernia repairs in the resident-surgeon and the staff-surgeon groups were 99 vs. 88 min, respectively (p < 0.05), and 130 vs. 137 min, respectively. There was no significant difference in the incidence of conversion to a different procedure between the groups. The mean postoperative hospital stay was 2.0 days for patients from the resident-surgeon group vs. 2.8 days for those from the staff-surgeon group (p < 0.05). Seromas and wound infections developed in 8 % (12/148) of patients from the resident-surgeon group vs. 12 % (19/153) of those from the staff-surgeon group. No other major complications or hernia recurrence were noted in either group.

CONCLUSIONS

SILS-TEP was performed safely, with low morbidity and no recurrence, by the resident surgeons under appropriate guidance by staff surgeons.

Cancer immunotherapy for pancreatic cancer utilizing α-gal epitope/natural anti-Gal antibody reaction

Pancreatic ductal adenocarcinoma (PDAC) has the poorest prognosis of all malignancies and is largely resistant to standard therapy. Novel treatments against PDAC are desperately needed. Anti-Gal is the most abundant natural antibody in humans, comprising about 1% of immunoglobulins and is also naturally produced in apes and Old World monkeys. The anti-Gal ligand is a carbohydrate antigen called “α-gal epitopes” with the structure Galα1-3Galβ1-4GlcNAc-R. These epitopes are expressed as major carbohydrate antigens in non-primate mammals, prosimians, and New World monkeys. Anti-Gal is exploited in cancer vaccines to increase the immunogenicity of antigen-presenting cells (APCs). Cancer cells or PDAC tumor lysates are processed to express α-gal epitopes. Vaccination with these components results in in vivo opsonization by anti-Gal IgG in PDAC patients. The Fc portion of the vaccine-bound anti-Gal interacts with Fcγ receptors of APCs, inducing uptake of the vaccine components, transport of the vaccine tumor membranes to draining lymph nodes, and processing and presentation of tumor-associated antigens (TAAs). Cancer vaccines expressing α-gal epitopes elicit strong antibody production against multiple TAAs contained in PDAC cells and induce activation of multiple tumor-specific T cells. Here, we review new areas of clinical importance related to the α-gal epitope/anti-Gal antibody reaction and the advantages in immunotherapy against PDAC.

Abstract 556: The detection of viable human circulating tumor cells (v-hCTCs) in resectable pancreatic cancer induced by neoadjuvant chemoradiotherapy (NACRT) using gemcitabine, S-1 and intensity-modulated radiotherapy (IMRT)

Circulating tumor cells (CTCs) are thought to be “metastatic intermediates”. Recently, we reported encouraging survival rates following neoadjuvant therapy using gemcitabine (Gem) and S-1 concurrently with radiotherapy (NACRT) in patients (pts) with resectable pancreatic cancer (PC). However, NACRT may have disadvantages. We hypothesized that NACRT in PC may induce epithelial to mesenchymal transition (EMT), which is associated with metastasis followed by the increase of CTCs. To extend our assessment of EMT during NACRT, we investigate the results of the v-hCTC detection in the pts treated with NACRT. This study was a single institution trial, approved by the Kure Medical Center IRB. Pts with resectable cytologically or histologically proven ductal adenocarcinoma of the pancreas were enrolled. Treatment consisted of an intervenous infusion of Gem 800 mg/m2 on day 1, 8, 22, and 29; and S-1 80 mg/m2 orally on day 1-5, 8-12, 22-26, and 29-33 given concurrently with IMRT to 60 Gy (2 Gy/day, 5 times per week, 30 fractions). Surgical exploration was scheduled 4-7 weeks after the final radiation fraction. To detect v-hCTCs, we employed a telomerase-specific replication-selective adenovirous expressing GFP (TelomeScan F35). 7.5 ml of blood samples were obtained from the pts included in this clinical study before NACRT, after 1 month of NACRT, and after 2 months of surgical resection. To distinguish between leucocyte and cells with epithelial origin, cells were stained with anti-CD45 and anti-Cytokeratin Abs. To distinguish cells with mesenchymal origin, cells were labeled with anti-Vimentin Ab. GFP-positive and CD45-negative cells were counted as v-hCTC. 12 pts aged 44-77 years (2 males and 10 females) were enrolled. No treatment-related deaths occurred. CA19-9 was reduced to &lt;50% of baseline values in 7 of 9 measureable pts. 11 of 12 enrolled pts successfully underwent surgical resection. Only 4 out of 12 pts had one or two v-hCTCs detected before NACRT. After NACRT, 6 of 12 pts without tumor progression had v-hCTCs detected, which expressed Vimentin (1-56 CTCs). Among them, 3 pts had v-hCTCs detected at baseline. These 3 CTC-positive pts still had two or more Vimentin-positive CTCs detected (2-27 CTCs) after surgery, whereas remaining 9 pts had no detectable v-hCTCs. 1 of these 3 CTC-positive pts early developed liver metastasis and died, despite R0 resection. For the remaining 2 CTC-positive pts after surgery, one pt with postoperative therapy had no detectable CTCs at 1 year after surgery, however another pt without postoperative therapy still had 7 v-hCTCs detected (Vimentin[+]). We believe that our NACRT is feasible. However, we may consider “surgery first” for CTC-positive PC pts at baseline. In conclusion, v-hCTCs may become useful for prognosis assessment or stratification, especially when radiotherapy is considered.

Citation Format: Masahiro Tanemura, Toshimitsu Irei, Masashi Inoue, Shinya Yamashita, Kenta Furukawa, Masaki Wakasugi, Kentaro Kishi, Hiroaki Nagano, Hiroki Akamatsu, Yasuo Urata, Nobuyoshi Hatanaka, Masaki Mori, Yuichiro Doki. The detection of viable human circulating tumor cells (v-hCTCs) in resectable pancreatic cancer induced by neoadjuvant chemoradiotherapy (NACRT) using gemcitabine, S-1 and intensity-modulated radiotherapy (IMRT). [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 556. doi:10.1158/1538-7445.AM2015-556

Abstract 2512: Novel immunotherapy using a tumor lysate vaccine with α-gal epitopes against pancreatic cancer

Pancreatic cancer (PC) is a lethal disease that remains one of the most resistant to traditional therapies, so we are in urgent need of other therapies. Immunotherapies act differently than chemotherapy or radiotherapy and might be an alternative treatment modality to this deadly disease with significantly less toxicity. Immunotherapy designed to target tumor-associated antigens (TAAs) is a promising treatment approach for PC. But vaccination against a single TAA seems to be insufficient. In our previous study, we showed effectiveness vaccination by whole PC cells engineered to express α-gal epitopes (Cancer Res, 2010). Subsequently we showed effectiveness of tumor lysate vaccine engineered to α-gal epitopes (Int J Oncol, 2015). For clinical development of more effective immunotherapy, we proposed that human tumor lysate originated from resected PC is more suitable because it contains several TAAs that could elicit a marked anti-tumor response. The present study addresses the effectiveness of elicitation of both antibody production and in vivo destruction against PC by vaccination with human tumor lysate with α-gal epitopes enzymatically.

Tumor specimens were obtained from 11 patients at the time of surgical resection. To express α-gal epitopes, we cloned the α1,3galactosyltransferas (α1,3GT) from a New World Monkey and expressed it in a soluble form in the yeast expression system of Pichia pastoris. α1,3GT KO mice were immunized with pig tissue to generate anti-Gal Ab in their sera. These mice were vaccinated intraperitoneally by either unsynthesized (control group; group C) or α-gal tumor lysate (α-gal group; group A).

Production of anti-PC cell Ab in group A was 8∼16-fold higher than that of group C. Also production of anti-TAA Ab in group A was 8∼16-fold higher than that of group C. Expansion of TAAs-specific B cells was significantly higher [number of spots at 1×106 splenocytes: MUC1: group A vs. C; 151±33 vs. 28±13 (p&lt;0.001), Mesothelin: 97±26 vs. 36±19 (p = 0.03)]. In group A, we detected 828±180 spots of IFN-γ secreting T cells in the presence of the MUC1, and 988±232 spots were detected in the presence of the Mesothelin. In group C, 146±59 spots by the MUC1 and 384±219 spots by the Mesothelin were detected. The number of spots in the presence of TAA stimulation was significantly higher in group A than in group C. To demonstrate in vivo tumor destruction, an animal experiment was performed. Splenocytes from vaccinated KO mice were prepared, and then transferred intraperitoneally (90×106 cells) into NOD/SCID mice. Followed by transferring, mice were challenged with 1×107 of live PANC-1 cells. In mice from group A, regrowth of tumors was significantly prevented and survival period was significantly prolonged [group A vs. C: 91.5 vs. 47.0 days (p&lt;0.01)].

We conclude that immunotherapy with α-gal tumor lysate obtained from PC patients with enzymatic engineering could be more effective and practicable methods for PC treatment.

Citation Format: Kenta Furukawa, Masahiro Tanemura, Eiji Miyoshi, Hiroaki Nagano, Masaki Wakasugi, Toru Masuzawa, Mitsuyoshi Tei, Kentaro Kishi, Hiroki Akamatsu, Hidetoshi Eguchi, Katsuyoshi Matsunami, Masaki Mori, Yuichiro Doki. Novel immunotherapy using a tumor lysate vaccine with α-gal epitopes against pancreatic cancer. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 2512. doi:10.1158/1538-7445.AM2015-2512

New approaches in laparoscopic surgery for colorectal diseases: The totally laparoscopic and single-incision approaches

More than 20 years have passed since the first report of laparoscopic colectomy in 1991. Thereafter, laparoscopic surgery for the management of colorectal diseases has been widely accepted as a prevailing option because of improved cosmetic outcomes, less postoperative pain, and shorter hospital stay in comparison with open surgery. To further the principle of minimally invasive surgery, two new approaches have been developed in this rapidly evolving field. The first is the totally laparoscopic approach. Currently most of standard techniques inevitably involve an abdominal incision for retrieval of the specimen and preparation for anastomosis, which might compromise the benefits of laparoscopic surgery. The totally laparoscopic approach dispenses with this incision by combining completely intraperitoneal anastomosis with retrieval of the specimen via a natural orifice, such as the anus or the vagina. Our new and reliable technique for intraperitoneal anastomosis is also described in detail in this article. The second is the single-incision approach. While three to six ports are needed in standard laparoscopic surgery, the single-incision approach uses the umbilicus as the sole access to the abdominal cavity. All of the laparoscopic procedures are performed entirely through the umbilicus, in which the surgical scar eventually becomes hidden, achieving virtually scarless surgery. This article reviews the current status of these two approaches and discusses the future of minimally invasive surgery for colorectal diseases.

Clinicopathological Significance of Leucine-Rich α2-Glycoprotein-1 in Sera of Patients With Pancreatic Cancer

OBJECTIVES

Leucine-rich α2-glycoprotein-1 (LRG-1) is an inflammatory protein. Serum LRG-1 levels can reportedly be used as a cancer biomarker for several types of carcinoma. In the present study, we investigated the clinical usefulness of serum LRG-1 levels as a biomarker of pancreatic cancer.

METHODS

A total of 124 patients with pancreatic cancer, 35 patients with chronic pancreatitis (CP), and 144 healthy volunteers were enrolled in the study. Serum LRG-1 levels were assayed by enzyme-linked immunosorbent assay. Immunohistochemistry was used to examine LRG-1 expression in pancreatic cancer tissues.

RESULTS

Serum LRG-1 levels were significantly increased in patients with pancreatic cancer compared with CP patients and healthy volunteers. The LRG-1 levels increased with progressive clinical stages of pancreatic cancer. Receiver operator curve analysis showed that a combination of carbohydrate antigen 19-9 and LRG-1 resulted in a higher area under the curve for the diagnosis of pancreatic cancer. Positive staining was observed in all cases of pancreatic cancer, but positive signal was scarcely detected in tissues from CP patients or normal surrounding tissue.

CONCLUSIONS

These results suggest that serum LRG-1 is a promising biomarker for pancreatic cancer.

[A case of advanced gastric cancer with liver metastasis involving curative surgery after neoadjuvant chemotherapy]

A 77-year-old-woman, whose chief complaint was anemia, was referred to our hospital and diagnosed with advanced gastric cancer with liver metastasis and lymph node metastasis.Gastrointestinal endoscopy showed a tumor on the lesser curvature of the gastric corpus.Histologically, biopsy specimens indicated adenocarcinoma with genetic amplification of human epidermal growth factor receptor type 2.Computed tomography and magnetic resonance imaging showed lymph node metastasis and liver metastasis.The patient received a total gastrectomy and a partial liver resection after combination chemotherapy consisting of capecitabine, cisplatin, and trastuzumab.Histopathological examination of a resected specimen showed a minute residual cancer nest at the subserosa of the stomach and lymph node metastasis, but no liver metastasis. This combined modality therapy can be considered an effective treatment for gastric cancer with liver metastasis, and we hope that it will be established as a standard therapy.

Pancreatic cancer immunotherapy using a tumor lysate vaccine, engineered to express α-gal epitopes, targets pancreatic cancer stem cells

Pancreatic cancer is a lethal disease that remains one of the most resistant to traditional therapies. Immunotherapy in pancreatic cancer induces the recruitment and activation of T cells that recognize tumor-associated antigens (TAAs); thus, the mechanism differs from that of chemotherapy and radiotherapy. The goal of cancer immunotherapy is to elicit immune responses against autologous tumors, and especially to induce multiple T cell clones against a variety of TAAs. In the present study, we prepared a polyvalent tumor lysate vaccine engineered to express the α-gal epitopes, Galα1-3Galβ1-4 GlcNAc-R (i.e., α-gal tumor lysate), from primary tumors. The vaccine elicited strong antibody production against multiple TAAs in pancreatic cancer cells and induced activation of multiple tumor-specific T cells in α1,3-galactosyltransferase (α1,3GT) knockout (KO) mice. The tumor lysate vaccine exhibited a similar effect on pancreatic cancer stem cells (CSCs) with the CD44+CD24+ phenotype. Furthermore, in vivo experiments using NOD/SCID mice, inoculated with splenocytes from KO mice vaccinated with the α-gal tumor lysate and injected with pancreatic cancer cells, showed successful induction of a marked immune response that resulted in suppression of tumorigenesis and significant improvement in overall survival. In contrast, inoculation of lymphocytes from KO mice vaccinated with control tumor lysate vaccine had no effects on tumor growth and survival. The results of both in vitro and in vivo experiments emphasize the efficiency of tumor lysate vaccines expressing α-gal epitopes in targeting all pancreatic cancer cells, including differentiated cancer cells and pancreatic CSCs. The α-gal tumor lysate vaccine could be the basis for a novel therapeutic approach in human clinical trials.

Abstract 2560: Strong cross-reactive responses to pancreatic cancer cells induced by α-gal epitopes-expressing tumor lysate and their implications for a universal cancer vaccine

We investigated the effects of whole cell vaccination with α-gal epitopes-expressing pancreatic cancer (PC) cells (Cancer Res; 70 (13); 5259-69, 2010) and examined the usefulness of this vaccine in the induction of specific anti-tumor-responses and improvement of survival. But, these effects were somewhat weak. We hypothesized that tumor lysate (t-ly), which contains many tumor-associated antigens (TAAs) of both PC and stromal cells is a suitable vaccination material and it can elicit a broadly protective anti-tumor responses. In this study, we investigate that vaccination with α-gal epitopes-expressing PC t-ly can induce cross-reactive protections to heterosubtypic PC cells. Human PC cell lines, BxPC3 (Bx), expressing Mesothelin, and MiaPaCa (Mia), expressing MUC1 were employed. PC cell lines were injected s.c. into NOD/SCID mice. The grown tumors were enucleated and homogenized for making t-ly. To synthesize α-gal epitopes on t-ly, we cloned the α1,3 galactosyltransferase (α1,3GT) cDNA from a New World monkey and isolated a soluble form of enzyme in the yeast expression system of Pichia pastoris. These t-lys were incubated with UDP-Gal and α1,3GT. α1,3GT KO mice were immunized with pig tissues to produce anti-Gal Ab. The high anti-Gal KO mice were vaccinated intraperitoneally by either parental (control group; Bx-t-ly or Mia-t-ly) or α-gal-t-ly (α-gal group; α-gal-Bx-t-ly or α-gal-Mia-t-ly). No expression of α-gal epitopes were observed in parental t-lys, whereas high expression levels were clearly detected on α-gal-t-lys. α-gal-Bx-t-ly vaccination elicited strong responses of anti-Bx IgG and anti-Mesothelin IgG, whereas Bx-t-ly vaccination did not induce such Ab responses. For Mia-t-ly vaccination, KO mice of α-gal group clearly induce anti-Mia IgG and anti-MUC1 IgG, but no Ab responses were observed in control group. Productions of either anti-Bx or anti-Mia IgG in α-gal group were 64-fold higher than those in control group. α-gal-Bx-t-ly vaccinated KO mice abundantly produced cross-reactive IgG Abs to Mia cells, whereas no cross-reactive humoral responses to Mia cells were induced by Bx-t-ly vaccine. Vaccinated mice sera from α-gal-Mia-t-ly strongly cross-react to Bx cells. To demonstrate in vivo tumor destruction, splenocytes from vaccinated KO mice were prepared, and these splenocytes were inoculated i.p. into NOD/SCID mice. Either live Bx or Mia cells were challenged with s.c. injection. Both Bx and Mia tumors in mice inoculated from parental group reached the size of 100 mm2 at approximately 22 days after injection. For tumors in mice transferred from α-gal group, no regrowth tumors were identified. We conclude that α-gal epitopes-expressing t-ly vaccine can elicit durable and broadly protective immune response to subtypic PC cells, and that such vaccination may provide implications for a universal cancer vaccine to cure for the patients with PC.

Citation Format: Masahiro Tanemura, Eiji Miyoshi, Hiroaki Nagano, Masafumi Inoue, Toshimitsu Irei, Shinya Yamashita, Kenta Furukawa, Katsuyoshi Matsunami, Wataru Kamiike, Masaki Mori, Yuichiro Doki. Strong cross-reactive responses to pancreatic cancer cells induced by α-gal epitopes-expressing tumor lysate and their implications for a universal cancer vaccine. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 2560. doi:10.1158/1538-7445.AM2014-2560

Abstract 2884: Immune-based therapy with human tumor lysate, expressing α-gal epitopes induce significant B cell response and in vivo tumor destruction against pancreatic cancer

Current strategies in the treatment of advanced pancreatic cancer (PC) offer little hope for a cure. Now treatment modalities, including immunotherapy are warranted for PC, which easily metastasizes in many organs. Although MUC1 and Mesothelin are potential targets for the immunotherapy, vaccination against a single tumor-associated antigen (TAA) seems to be insufficient. In our previous study, we showed the in vitro and in vivo effectiveness of immunotherapy though vaccination with whole PC cells engineered to express α-gal epitopes (Cancer Res; 70(13); 5259-69, 2010). It was thought that the immunogenicity of well-known as well as unknown multiple TAAs in cancer cells was upregulated by addition of α-gal epitopes and these TAAs ultimately lead to polyclonal expansion of both B and T cells. For clinical development of more effective immunotherapy, we proposed that human tumor lysate originated from resected PC is more suitable because it contains several TAAs that could elicit a marked anti-tumor response. The present study addresses the effectiveness of elicitation of both antibody production and in vivo destruction against PC by vaccination with human tumor lysate from PC patients, expressing α-gal epitopes enzymatically. Tumor specimens were obtained from 11 patients at the time of surgical resection. To express α-gal epitopes, we cloned the α1,3galactosyltransferas (α1,3GT) from a New World Monkey and expressed it in a soluble form in the yeast expression system of Pichia pastoris. For synthesis of α-gal epitopes, tumor tissues were homogenized in MES buffer, and incubated with MnCl2, UDP-Gal and α1,3GT for 4 hours at 37°C. α1,3GT KO mice were immunized with pig tissue to generate anti-Gal Ab in their sera. These mice were vaccinated intraperitoneally by either unsynthesized (control group) or α-gal tumor lysate (α-gal group). Production of anti-PC cell Ab in α-gal group was 4∼8-fold higher than that of control group. Anti-TAA Ab production was also markedly increased in comparison with that in control group (anti-MUC1 2-fold, anti-Mesothelin 4-fold). Expansion of TAAs-specific B cells was significantly higher [number of spots at 1×106 splenocytes: MUC1: α-gal vs. control; 414±26 vs. 178±46 (p=0.015), Mesothelin: 401±56 vs. 209±19 (p=0.03)]. To demonstrate in vivo tumor destruction, an animal experiment was performed. Splenocytes from vaccinated KO mice were prepared, and then transferred intraperitoneally (90×106 cells) into NOD/SCID mice. Followed by transferring, mice were challenged with 1×107 of live PANC-1 cells. In mice from α-gal group, regrowth of tumors was significantly prevented and survival period was significantly prolonged [α-gal vs. control: 91.5 vs. 43.3 days (p=0.03)]. We conclude that immunotherapy with α-gal tumor lysate obtained from PC patients with enzymatic engineering could be more effective and practicable methods for PC treatment.

Citation Format: Kenta Furukawa, Masahiro Tanemura, Eiji Miyoshi, Hiroaki Nagano, Hidetoshi Eguchi, Toshimitsu Irei, Masashi Inoue, Shinya Yamashita, Yoshito Tomimaru, Naoki Hama, Hiroshi Wada, Koichi Kawamoto, Shogo Kobayashi, Katsuyoshi Matsunami, Kiyomi Taniyama, Wataru Kamiike, Masaki Mori, Yuichiro Doki. Immune-based therapy with human tumor lysate, expressing α-gal epitopes induce significant B cell response and in vivo tumor destruction against pancreatic cancer. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 2884. doi:10.1158/1538-7445.AM2014-2884

Neoadjuvant gemcitabine-based accelerated hyperfractionation chemoradiotherapy for patients with borderline resectable pancreatic adenocarcinoma

OBJECTIVE

We report the response to pre-operative gemcitabine-based chemoradiotherapy for pancreatic adenocarcinoma.

METHODS

Thirty-five consecutive patients with borderline resectable pancreatic adenocarcinoma of UICC Stage II or III with portal vein invasion or tumor abutment of artery received radiotherapy (twice daily fractions of 1.5 Gy, 5 days/week, total dose: 36 Gy; 30 Gy for Phase I Level 1) with weekly intravenous infusions of gemcitabine (400, 600 and 800 mg/m(2)) at Days 1 and 8 for Phase I and 800 mg/m(2) for Phase II. Restaging was repeated after completion of chemoradiotherapy.

RESULTS

Twenty-six of the 35 (74.3%) patients underwent resection. The dose-limiting toxicities were Grade 4 neutropenia and thrombocytopenia. The recommended regimen was total radiation dose of 36 Gy with gemcitabine 800 mg/m(2). Surgical resection was conducted in 11 of the 15 (73.3%) patients in Phase I study and 15 of the 20 (75.0%) in Phase II. After recommended dose chemoradiotherapy and surgical resection, the median disease-free survival was 17.4 months (5-year survival rate = 14.3%). The median overall survival time and 5-year survival rate were 41.2 months and 28.6%, respectively, for the 21 patients who underwent resection and 10.0 months and 0%, respectively, for those 5 who did not (P = 0.004).

CONCLUSION

Our pre-operative gemcitabine-based chemoradiotherapy was well tolerated and safe.

[Case of advanced colon cancer after colostomy closure]

We report a case of advanced colon cancer after closure of a colostomy. A 77-year-old man suddenly began experiencing abdominal pain and pan-peritonitis due to perforate diverticulum of the sigmoid colon. A Hartmann operation was urgently performed, and closure of the colostomy was performed 6 months later. The patient had no history of colonoscopy. Colonoscopy was performed 45 months after the closure of the colostomy to examine the colon. Advanced colon cancer was detected near the anastomotic region. In conclusion, older patients, including those with numerous disease complications such as diabetes and hypertension, should undergo early colonoscopy as a preventative measure.

Effect of in vivo administration of reprogramming factors in the mouse liver

Cancer is initiated by the transformation of stem cells or progenitor cells via a dedifferentiation process that leads to cancer stem cells; however, the process involves the activation of growth-promoting oncogenes and the inactivation of growth-constraining tumor suppressor genes. The introduction of defined factors, such as those encoded by c-Myc, Sox2, Oct3/4 and Klf4, in normal somatic cells results in their dedifferentiation into induced pluripotent stem (iPS) cells. We previously reported that these defined factors induced the development of induced multipotent cancer (iPC) cells from gastrointestinal cancer cells by reducing tumor aggressiveness. Previous studies indicated that although reprogramming may be facilitated by p53 inhibition, gain-of-function oncogenic mutations in p53 and oncogenic mutations in Kras-stimulated tumorigenic activity, and their roles in vivo are imperfectly understood. Hence, in the present study, the effect of direct injection of a Sendai virus (SeV) vector encoding four defined factors in vivo was studied using various backgrounds of transgenic and knockout mice, and was compared with that of direct injection of microRNAs (miRNAs) diluted with cationic lipid. The in vivo imaging data revealed transformation hot spots for p53 deficiency or conditional activation of mutant Kras, and the sizes were concordant with those in immuno-deficient NOD/SCID and uPA-NOG mice, as well as larger compared with those in the control mice. Overall, the present data on in vivo reprogramming indicated that Kras activation may facilitate the effect of cellular reprogramming in normal liver cells, and the effect of Kras activation is more apparent than that of tumor suppressor p53 deficiency. The results also revealed that immunodeficiency may increase the effect of reprogramming, presumably by blocking the immunosurveillance of transformed cells. These findings provide a rationale for further studies to develop a therapeutic approach involving direct in vivo reprogramming.

Preoperative chemoradiotherapy, surgery and adjuvant therapy for resectable pancreatic cancer

BACKGROUND/AIMS

In order to improve the poor prognosis of pancreatic cancer, a combination therapy consisting of preoperative chemoradiotherapy, surgery and postoperative chemotherapy may be an ideal strategy; nevertheless, the influence of preoperative therapy to postoperative therapy is not investigated.

METHODOLOGY

Thirty patients with resectable pancreatic ductal adenocarcinoma were enrolled. A 40Gy of radiation (2Gy/day x 20 fractions/4 weeks) was administered together with intravenous infusion of gemcitabine (800mg/m2, days 1, 8 and 15) before surgery. Surgery was performed 3-7 weeks after the final fraction of radiation, and postoperative chemotherapy consisting of 1000mg/m2 gemcitabine (days 1, 8 and 15 every 4 weeks for 6 cycles) was started within 8 weeks after surgery.

RESULTS

All 30 patients successfully completed preoperative therapy. Re-staging after such therapy showed radiologically unresectable disease in 4 patients and 1 patient rejected surgery. Among the 25 patients who underwent laparotomy, 21 underwent curative resection. After curative resection, 4 were inadequate in performance status, thus postoperative therapy could not be started. Ten patients completed postoperative adjuvant therapy.

CONCLUSIONS

The combination therapy for resectable pancreatic cancer seems a feasible and effective approach, though preoperative therapy may reduce the feasibility of postoperative therapy.

Abstract 2833: Significant protection against gemcitabine-resistant pancreatic cancer cells with tumor lysate vaccine, engineered to express α-gal epitopes

Gemcitabine(Gem)-based chemotherapy is typically offered as a standard care of pancreatic cancer (PC) patients. However most of patients do not survive longer than 6 months, as the PC cells are naturally resistant to current chemotherapy. New therapeutic approaches need to be encouraged. Human natural anti-Gal is an IgG known to be presented in large amounts (∼1% of circulating IgG) in normal subjects and cancer patients. Anti-Gal specifically interacts with α-gal epitopes (Galα1, 3Galβ1, 4GlcNAc-R), synthesized by α1, 3 galactosyltransferase (α1, 3GT) on cell surface glycolipids and glycoproteins. We previously showed the in vitro and in vivo effectiveness of new immunotherapy by vaccination with whole PC cells, expressing α-gal epitopes (Cancer Res; 70(13); 5259-69, 2010). For the clinical development, we proposed that tumor lysate is a suitable source of tumor-associated antigens (TAAs), because it contains several known as well as unknown TAAs that could elicit an anti-tumor immune response against heterogeneous PC cell populations, including Gem-resistant PC cells (Gem-resi cells). In this study, we investigate whether vaccination by PC tumor lysate, expressingα-gal epitopes can efficiently induce anti-tumor response against both PC cells and gem-resi cells. A human PC cell line, PANC1 was transfected by α1,3GT gene (α-gal PANC1), 2×106 of either parental or α-gal PANC1 were injected s.c. into NOD/SCID mice. The grown PANC1 tumors were enucleated and homogenized. α1,3GT KO mice were pre-immunized with pig tissues to produce anti-Gal in their sera like human. These mice were vaccinated intraperitoneally by 10 mg of either parental (control group) or α-gal PANC1 tumor lysate (α-gal group). Tumor lysate of parental PANC1 lacked of α-gal epitopes and it of α-gal PANC1 expressed ∼40 × 106 of these epitopes per 1mg of lysate. To demonstrate in vivo tumor destruction, an animal model was performed. Splenocytes from vaccinated KO mice were prepared, and these cells were transferred ip (30×106 cells/ip ×3 times) into NOD/SCID mice. Transferred mice were challenged with S.C. injection by either 1×107 of live PANC1 or gem-resi PANC1. PANC1 tumors in mice transferred from parental group reached the size of 100 mm2 at 40.3 days after injection. For tumors in mice from α-gal group, regrowth of tumor was completely prevented. Survival of α-gal transferred mice was prolonged [α-gal vs. parental: 82.5±21.9 vs. 48.0±6.7 days, p&lt;0.0001]. For gem-resi tumors in mice from α-gal group, regrowth of them was markedly protected [size of 100 mm2; α-gal vs. parental: 74.3 vs. 37.4 days]. Survival was prolonged [α-gal vs. parental: 93.6±17.7 vs.46.2±7.3 days, p=0.0018]. In conclusion, immunotherapy with tumor lysate vaccine, expressing α-gal epitopes effectively targets both PC cells and gem-resi cells and may provide PC cure by the elimination of the replenishing pool of all PC cells.

Citation Format: Masahiro Tanemura, Eiji Miyoshi, Tsukasa Tanida, Hiroaki Nagano, Hidetoshi Eguchi, Kenta Furukawa, Yuji Nonaka, Hirofumi Akita, Naoki Hama, Hiroshi Wada, Koichi Kawamoto, Shyogo Kobayashi, Kiyomi Taniyama, Wataru Kamiike, Masaki Mori, Yuichiro Doki. Significant protection against gemcitabine-resistant pancreatic cancer cells with tumor lysate vaccine, engineered to express α-gal epitopes. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 2833. doi:10.1158/1538-7445.AM2013-2833

PTK787/ZK222584 combined with interferon alpha and 5-fluorouracil synergistically inhibits VEGF signaling pathway in hepatocellular carcinoma

BACKGROUND

The prognosis of patients with hepatocellular carcinoma (HCC) and portal vein tumor thrombus remains poor. We previously reported the beneficial effects of interferon alpha (IFN) and 5-fluorouracil (5-FU) combination therapy for these patients. We showed that the mechanism of therapy was regulation of vascular endothelial growth factor (VEGF). Here, we combined IFN/5-FU therapy with the VEGF receptor-selective inhibitor PTK787/ZK222584 (PTK/ZK) and examined the antitumor effects and the mechanism of action.

METHODS

We studied two HCC cell lines, PLC/PRF/5 and HuH7, and a human umbilical vein endothelial cell line, HUVEC. We studied the effects of IFN/5-FU with or without PTK/ZK in growth inhibition assays, immunohistochemistry, Western blot analysis, and immunocytochemistry.

RESULTS

In a HuH7 xenograft model, the combination of PTK/ZK and IFN/5-FU significantly inhibited proliferation, induced apoptosis, decreased microvessel density, reduced the number of tumor cells that expressed VEGF receptor 2 (VEGFR-2), and repressed the phosphorylation of Akt in vivo. In HCC cells and HUVECs in vitro, IFN/5-FU plus PTK/ZK repressed the expression of VEGFR-2 and repressed the phosphorylation of VEGFR, Akt, Erk, and p38MAPK.

CONCLUSIONS

VEGF signaling inhibition enhanced the antitumor effects of IFN/5-FU therapy on HCC cells and endothelial cells via Erk, Akt, and p38MAPK pathways.

Fibrin sealant with PGA felt for prevention of bile leakage after liver resection

BACKGROUND/AIMS

Fibrin sealing are used to prevent postoperative hemorrhage and biliary leakage. However, the use of fibrin sealant alone is insufficient, thus requiring a kind of supportive material. Polyglycolic acid (PGA) felt was developed as a synthetic material to cover tissue defects. We performed preliminary evaluation of fibrin sealing combined with PGA felt (PGA-FS) as hemostat and to prevent biliary leakage, in comparison with the conventional fibrin-coated collagen fleece (FC-CF), retrospectively.

METHODOLOGY

Between 2007 and 2008, PGA-FS was used in 34 patients, while FC-CF in 39 patients. We compared the incidence of biliary leakage, postoperative hemorrhage, surgical site infection, volume of ascites and the duration of hospital stay between the groups. Biliary leakage was diagnosed when the drain fluid/serum bilirubin ratio was >5.

RESULTS

There were no significant differences of the patients' characteristics between the groups except for the surgical procedure. None of the patients experienced postoperative hemorrhage. Biliary leakage was noted in 4 of 39 patients with FC-CF but in none of the PGA-FS group (p<0.05). Various other postoperative parameters were similar in the two groups.

CONCLUSIONS

The results showed that the PGA-FS would be effective in preventing biliary leakage, compared with the FC-CF.

Adipose-derived mesenchymal stem cells and regenerative medicine

Adipose tissue-derived mesenchymal stem cells (ADSCs) are multipotent and can differentiate into various cell types, including osteocytes, adipocytes, neural cells, vascular endothelial cells, cardiomyocytes, pancreatic β-cells, and hepatocytes. Compared with the extraction of other stem cells such as bone marrow-derived mesenchymal stem cells (BMSCs), that of ADSCs requires minimally invasive techniques. In the field of regenerative medicine, the use of autologous cells is preferable to embryonic stem cells or induced pluripotent stem cells. Therefore, ADSCs are a useful resource for drug screening and regenerative medicine. Here we present the methods and mechanisms underlying the induction of multilineage cells from ADSCs.

Role of α-gal epitope/anti-Gal antibody reaction in immunotherapy and its clinical application in pancreatic cancer

Pancreatic cancer is one of the most common causes of death from cancer. Despite the availability of various treatment modalities, such as surgery, chemotherapy and radiotherapy, the 5-year survival remains poor. Although gemcitabine-based chemotherapy is typically offered as the standard care, most patients do not survive longer than 6 months. Therefore, new therapeutic approaches are needed. The α-gal epitope (Galα1-3Galβ1-4GlcNAc-R) is abundantly synthesized from glycoproteins and glycolipids in non-primate mammals and New World monkeys, but is absent in humans, apes and Old World monkeys. Instead, they produce anti-Gal antibody (Ab) (forming approximately 1% of circulating immunoglobulins), which specifically interacts with α-gal epitopes. Anti-Gal Ab can be exploited in cancer immunotherapy as vaccines that target antigen-presenting cells (APC) to increase their immunogenicity. Tumor cells or tumor cell membranes from pancreatic cancer are processed to express α-gal epitopes. Subsequent vaccination with such processed cell membranes results in in vivo opsonization by anti-Gal IgG in cancer patients. The interaction of the Fc portion of the vaccine-bound anti-Gal with Fcγ receptors of APC induces effective uptake of the vaccinating tumor cell membranes by the APC, followed by effective transport of the vaccinating tumor membranes to the regional lymph nodes, and processing and presentation of the tumor-associated antigens. Activation of tumor-specific B and T cells could elicit an immune response that in some patients is potent enough to eradicate the residual cancer cells that remain after completion of standard therapy. This review addresses these topics and new avenues of clinical importance related to this unique antigen/antibody system (α-gal epitope/anti-Gal Ab) and advances in immunotherapy in pancreatic cancer.

Clinicopathological features of long-term survivors for advanced biliary tract cancer and impact of the number of lymph nodes involved

BACKGROUND & AIM

To investigate the characteristics of long-term survivors after surgery for advanced biliary tract cancer (BTC), especially those with local invasion and/or lymph node involvement.

METHODS

We analyzed the features of long-term survivors using a prospectively collected database and verified the results using recent patients' data which have been well-described, especially in relation to lymph node dissection and metastasis. We used classification by the Japanese Society of Biliary Surgery (JSBS).

RESULTS

Among 170 patients with advanced BTC (Stage III or IV in JSBS), 25 (10 bile duct cancer, 9 gall bladder cancer, and 6 cancer of the papilla of Vater) survived for more than 5 years. Twenty-four patients had undergone fCurA/B (R0) surgery in these 25 patients. In comparison with the patients who did not survive for 5 years, the long-term survivors had fewer metastatic lymph nodes, that is, up to three (p = 0.0028). In regard to the impact of lymph node metastasis, the prognostic factor was the number of lymph nodes (3-year overall survival, 0 or 1: 68.1% vs >2: 40.0%, p = 0.0304).

CONCLUSION

For obtaining long-term survival, curative resection would be necessary in patients with no more than one lymph node metastasis.

[A case of advanced multiple hepatocellular carcinomas in both lobes that achieved long-term survival after repeated transcatheter arterial chemoembolization and surgical resection]

A 73-year-old man with advanced multiple hepatocellular carcinoma(HCC) in both lobes(S2, S3, S4, S8, and S1) was admitted to our hospital. Abdominal computed tomography revealed neither vascular invasion nor distant metastasis. Because 3 attempts of transcatheter arterial chemoembolization (TACE) resulted in successful control of the tumors in the right lobe, a left hepatic lobectomy was performed. Although postoperative recurrences were observed, they were controllable by repeated TACE, and the patient remains in a relatively good general condition 3 years and 8 months since the operation.

[A case of advanced hepatocellular carcinoma with inferior vena cava tumor thrombus and multiple intrahepatic metastases treated successfully by transcatheter arterial chemoembolization and radical hepatectomy]

A 76-year-old man, who had been treated with interferon-α(IFN-α) for hepatitis C, was diagnosed with multiple hepatocellular carcinomas (HCC; S7/8, S8, S5, S2) with right hepatic vein tumor thrombus (Vv2). He initially underwent transcatheter arterial chemoembolization(TACE). One month after TACE, the hepatic vein tumor thrombi extended into the inferior vena cava(Vv3). No distant metastasis was observed, and his liver function was well-preserved. Therefore, we performed a posterior segmentectomy, partial hepatectomy(S8, S5, S2), inferior vena cava tumor thrombus excision, and cholecystectomy. Four months after the operation, intrahepatic recurrences were detected, and these lesions were controlled via TACE. Four years and 2 months after the initial treatment, the patient survived and presently, is in a good condition. This case suggested that long-term survival is possible by surgery and repeated TACE in case of good liver function by a sustained virologic response (SVR) via treatment with IFN-α for hepatitis C virus.

[A case of advanced hepatocellular carcinoma with tumor thrombosis in the main trunk of the portal vein successfully treated by multidisciplinary therapies]

We report a case of advanced hepatocellular carcinoma(HCC) with tumor thrombosis in the main trunk of the portal vein successfully treated by multidisciplinary therapies. This case is that of a 61-year-old man with loss of appetite and weight loss. The abdominal computed tomography revealed an early enhanced and late wash-out lesion in the right hepatic lobe and tumor thrombosis in the major trunk of the portal vein. We diagnosed advanced HCC related to chronic hepatitis C [T4 (Vp4) N0M0, Stage IVA] and performed extended right lobectomy and extraction of the tumor thrombosis. The patient then underwent hepatic arterial infusion of 5-fluorouracil (5-FU) combined with systemic administration of interferon (IFN)-α therapy as an adjuvant therapy. Two years have passed since these therapies were performed with no recurrence of the disease. We expected that the patient would achieve long-term survival. Therefore, we administered IFN/ribavirin (RBV) therapy for chronic hepatitis C for 48 weeks. The patient is still alive, 44 months after the initial treatment. This case suggests that some patients with advanced HCC and a tumor thrombosis can achieve long-term survival by multidisciplinary therapies, including IFN-α/5-FU combination therapy.

[A case report of total remnant pancreatectomy for ductal carcinoma after distal pancreatectomy for invasive intraductal papillary mucinous carcinoma]

Recently, the number of case reports detailing cancer recurrence in the pancreatic remnants, following surgical resection of intraductal papillary-mucinous carcinoma (IPMC) of the pancreas has increased. We report the case of a 74-year-old woman who underwent pancreatic resection twice in a 3-year period for primary IPMC and remnant pancreatic ductal carcinoma. We first performed distal pancreatectomy for branched IPMC in the pancreatic tail. Histopathological examination revealed invasive IPMC and the negative margin of the pancreatic duct. The expression of tumor markers gradually increased in the 2 years and 4 months after the initial surgery, and a tumor was detected in the remnant pancreas. We performed total remnant pancreatectomy. The recurrent tumor consisted of moderately differentiated adenocarcinoma. Currently, the patient is alive without recurrence for a year since the second resection. This experience suggests that careful surveillance is necessary for IPMC.

[A case of hepatocellular carcinoma treated by transcatheter arterial chemoembolization and hepatectomy after subtotal stomach preserving pancreaticoduodenectomy for duodenal cancer]

Treatments for hepatocellular carcinoma(HCC) including surgical resection, transcatheter arterial chemoembolization (TACE), percutaneous local therapy, and systemic chemotherapy are decided upon according to tumor progression and liver function. However, it is difficult to choose a treatment after biliary tract reconstruction. Here we report a case of successful treatment for HCC and its recurrence where there had also been subtotal stomach preserving pancreaticoduodenectomy(SSPPD) for duodenal cancer. A 65-year-old female patient who had undergone SSPPD for duodenal cancer was found to have HCC in segment 8 (S8) 12 months later. Three months after super selective TACE, S8 partial resection was performed approaching through right thoracotomy and laparotomy. 2 years after the first hepatectomy, HCC was found to have reoccurred in S7/8 and S8. Right hepatic lobectomy was then performed without blocking the hepatic hilum. Liver resection was carried out with the aim of achieving A-P point. In this case then, several radical treatments have been completed without any biliary complication.

Structural studies of aluminium nitride embedded in amorphous carbon

Aluminum nitride containing diamond-like carbon was fabricated with pulsed laser deposition without post processing. The compositions of the targets used were varied at 1, 5, 10, 15 at.% and pure carbon was used as a reference. The films were comprehensively characterized with Atomic force microscope (AFM), X-ray photoelectron spectroscopy (XPS) and Transmission electron microscopy (TEM). Roughness analysis using AFM showed an increasing root-mean-square (RMS) roughness with increasing AIN content in target, while XPS analysis showed that the aluminum-nitrogen bonding was still present in the films after the fabrication process. Microstructural studies and selected area electron diffraction (SAED) pattern confirmed the presence of AIN crystals in DLC matrix. This nanostructured composite material is useful for luminescence applications.

Once-daily prolonged-release tacrolimus in de novo liver transplantation: a single center cohort study

BACKGROUND/AIMS

The feasibility of oral administration of once-daily prolonged-release tacrolimus (TAC-PR) in de novo liver transplantation is not clear and therefore was investigated further.

METHODOLOGY

The clinical profiles of 16 consecutive primary living donor liver transplantation (LDLT) recipients, who received oral TAC-PR once daily (TAC-PR group) between January 2009 and August 2010, were compared with those of 14 consecutive liver transplantation recipients given twice-daily tacrolimus (TAC; TAC group) between August 2006 and January 2009. Of the 14 patients in the TAC group, 9 received LDLT (TAC-L subgroup).

RESULTS

Patient characteristics were similar between groups. Trough levels of TAC during the first 3 months after liver transplantation were well-adjusted in both groups. Dose adjustment was more frequently required (31.3%) in the TAC-PR group and the total amount of TAC was significantly higher in the TAC-PR group (181.1±75.3mg) than in the TAC-L group (100.2±53.8mg, p=0.014). The incidence of biopsy-proven acute cellular rejection, renal dysfunction, other morbidities and hospital stay length were similar between groups.

CONCLUSIONS

Oral administration of TAC-PR for de novo liver transplantation recipients was well tolerated with similar safety and efficacy profiles as traditional twice-daily TAC with closely controlled adjustment of the TAC-PR dose.

Equivalent outcomes after anatomical and non-anatomical resection of small hepatocellular carcinoma in patients with preserved liver function

BACKGROUND

Although anatomical resection (AR) is considered better than non-anatomical resection (NAR) for the treatment for hepatocellular carcinoma (HCC), there is only limited evidence in support of this argument.

AIM

The aim of this study was to investigate whether AR is superior to NAR regarding postoperative outcomes in patients with small solitary HCC and preserved liver function.

METHODS

The study subjects were 92 curatively-resected patients with adequate liver function reserve (indocyanine green retention rate at 15 min <15%, prothrombin time >70%, serum albumin >3.5 g/dl) and macroscopically small (≤3.0 cm) solitary HCC without macroscopic vascular invasion; 30 patients underwent AR and 62 patients NAR. Postoperative short-term outcomes including mortality and morbidity and long-term outcomes were compared in the two groups.

RESULTS

There was no significant difference in clinicopathological background in the two groups. Although resected liver volume was significantly larger in the AR group than the NAR group (p < 0.0001), no significant differences were detected in the incidence of mortality or morbidity. For long-term outcomes, there were no significant differences between the two groups in disease-free survival or overall survival. Multivariate analysis showed that the extent of surgical procedure was not a significant prognostic factor for disease-free or overall survival.

CONCLUSIONS

AR of a solitary small HCC did not carry postoperative outcome advantages compared with NAR in patients with preserved liver function. We recommend NAR for hepatic resection of small solitary HCC in patients with preserved liver function.

Arterial stimulation and venous sampling for glucagonomas of the pancreas

BACKGROUND/AIMS

Arterial stimulation and venous sampling (ASVS) is a catheter-based diagnostic technique used to identify the localization of an insulinoma or gastrinoma. The aim of this study was to clarify the clinical significance of ASVS for glucagonomas.

METHODOLOGY

Eight patients with pancreatic hypervascular tumors and elevated serum glucagon levels in the peripheral blood were enrolled. Pancreatic angiography was performed and a bolus dose of calcium was injected into a suitable artery. Hepatic venous blood samples were then obtained to measure concentrations of glucagon and insulin. All patients underwent surgical resection, and the resected specimens were investigated immunohistochemically.

RESULTS

Compared to insulin, the glucagon levels stabilized after calcium stimulation in four patients, with a 1.2-fold increase or decrease. In the remaining four patients, there was a 1.6- to 5.8-fold increase in glucagon levels. The peak value of glucagon was observed at 90s or 120s which was slower than the insulin peak observed in patients with insulinoma. The patients with elevated glucagon levels during ASVS exhibited positive immunostaining of glucagon in resected specimens.

CONCLUSIONS

Increase in glucagon after calcium stimulation was observed in patients with glucagonomas. ASVS for glucagonomas may be useful in determining the most suitable surgical procedure.

Abstract 1560: Immune-based therapy with tumor lysate remodeled to express α-gal epitopes induce significant B- and T-cell responses against pancreatic cancer

Current strategies in the treatment of pancreatic cancer (PC) offer little hope for a cure. New treatment modalities, including immunotherapy are warranted for this type of cancer. In our previous study, we showed the in vitro and in vivo effectiveness of immunotherapy through vaccination with whole PC cells, remodeled to express α-gal epitopes (Cancer Res; 70(13); 5259-69, 2010). It was thought that the immunogenicity of well-characterized as well as uncharacterized multiple TAAs contained in cancer cells was upregulated by α-gal epitopes and these TAAs ultimately leaded to polyclonal expansion of both B and T cells. For the clinical development of more effective immunotherapy, we proposed that tumor lysate is a suitable source of TAAs, because it contains several known as well as unknown TAAs that could elicit an anti-tumor immune response. In this study, we investigated whether vaccination with PC tumor lysate, expressing α-gal epitopes can efficiently induce T cell response and antibody production against multiple TAAs. A human PC cell line, PANC1, which expresses MUC1 was employed and transfected with α1,3GT gene (α-gal PANC1), 2 × 106 of either parental or α-gal PANC1 were injected s.c. into NOD/SCID mice. The grown PANC1 tumors were enucleated for generating tumor lysate. α1,3GT KO mice were immunized with pig tissues to produce anti-Gal in their sera like human. These mice were vaccinated intraperitoneally by 10 mg of either parental (control group) or α-gal PANC1 tumor lysate (α-gal group). Tumor lysate of parental PANC1 lacked of α-gal epitopes and it of α-gal PANC1 clearly expressed ∼40 × 106 of these epitopes per 1mg of lysate. These tumor lysates express MUC1 at similar level. Specific proliferation, assessed by CFSE assay of both CD4+ and CD8+ T cells responses to either MUC1 peptide or PANC1 tumor lysate in α-gal group were significantly higher in comparison with these in control group [MUC1; CD4+ T cell: α-gal vs control; 12.1±3.7 vs 2.0±0.7% (p=0.0058), MUC1; CD8+ T cell: α-gal vs control; 8.2±1.4 vs 3.8±0.9% (p=0.036), Tumor lysate; CD4+ T cell: α-gal vs control; 71.3±7.0 vs 7.9±1.0% (p=0.0005), tumor lysate; CD8+ T cell: α-gal vs control; 20.2±2.8 vs 7.1±0.7% (p=0.0054)]. To prove the antibody production response to multiple TAAs, the presence of immunostained PANC1 proteins was investigated by Western blots, using mice sera before/after vaccination. The sera from control group did not display obvious bands that were recognized by anti-MUC1 Ab. In contrast, sera from α-gal group showed positive bands that bound to not only MUC1 but also different TAAs in PANC1 cells. These results suggested that vaccination with tumor lysate, remodeled to express α-gal epitopes enabled the immune system to generate multi-clonal B- and T-cell responses against a broad spectrum of tumor antigens and can provide a chance to develop the potential immunotherapy for PC patients.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 1560. doi:1538-7445.AM2012-1560

Abstract 1559: A new immunotherapy for pancreatic cancer stem cells by tumor lysate vaccine, expressing α-gal epitopes

Pancreatic cancer (PC) cells, expressing the markers CD44, CD24, and epithelial-specific antigen (ESA) were identified as PC stem cells (CSCs). Treatments targeting the CSCs may be more effective in resulting in PC cure, but traditional treatments, including chemo/radiation therapy can easily miss CSCs, because they are highly resistant to these therapies. Human natural Ab, anti-Gal is an IgG known to be present in large amounts in normal subjects and cancer patients, comprising ∼1% of serum circulating IgG. Anti-Gal specifically interacts with α-gal epitopes (Galα1, 3Galα1, 4GlcNAc-R), synthesized by α1, 3 galactosyltransferase (≥1,3GT) on cell surface glycolipids and glycoproteins. We hypothesized that biosynthesis of α-gal epitopes on the carbohydrate of CSC markers, including CD44, CD24 could effectively induce Ab production against CSCs and immune-mediate eradication of PC CSCs. To address this strategy, a human PC cell line, PANC1, which expresses MUC1 was employed and transfected with α1,3GT gene (α-gal PANC1). To generate tumor lysate, 2 X 106 of either parental or α-gal PANC1 were injected S.C. into NOD/SCID mice, and the grown tumors were enucleated and homogenized. High anti-Gal α1,3GT KO mice, which displayed anti-Gal titers similar to those found in humans, were generated by immunization of pig tissue. These mice were vaccinated intraperitoneally (ip) by 10mg of either parental (parental group) or α-gal PANC1 tumor lysate (α-gal group). We isolated PANC1 cells with CD44+CD24+ phenotype by magnetic beads and assessed Ab production toward both CSCs (binding PANC1 with beads) and differentiated cancer cells (unbinding PANC1 with beads). In FACS analysis, a marked Ab production against both CSCs and differentiated cancer cells were observed in α-gal group. To demonstrate in vivo tumor destruction, an animal model was performed. Splenocytes from vaccinated KO mice were prepared, then these cells were transferred ip (30X106 cells/ip X 3 times) into NOD/SCID mice. Transferred mice were challenged with S.C. injection with either 1 X 107 of live PANC1 or 5 X 106 of CD44+CD24+ PANC1. PANC1 tumors in mice transferred from parental group reached the size of 150 mm2 at 45 days after injection. For tumors in mice transferred from α-gal group, regrowth of tumor was completely prevented. Survival of α-gal transferred mice was significantly prolonged [α-gal vs. parental: 82.5±21.9 vs. 48.0±6.7 days, p&lt;0.0001]. CSC tumors in mice transferred from parental group reached the size of 100 mm2 at 49 days after injection. For CSC tumors in mice from α-gal group, no tumor formation was observed. Survival was significantly prolonged [α-gal vs. parental: 85.0±20.8 vs. 49.3±14.3 days, p=0.0002]. We conclude that immunotherapy with tumor lysate vaccine, expressing α-gal epitopes effectively targets both differentiated and PC CSCs and may provide PC cure by destruction of micro-metastasis and minimal residual cancer.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 1559. doi:1538-7445.AM2012-1559

Significant improvement in islet yield and survival with modified ET-Kyoto solution: ET-Kyoto/Neutrophil elastase inhibitor

Although islet transplantation can achieve insulin independence in patients with type 1 diabetes, sufficient number of islets derived from two or more donors is usually required to achieve normoglycemia. Activated neutrophils and neutrophil elastase (NE), which is released from these neutrophils, can directly cause injury in islet grafts. We hypothesized that inhibition of NE improves islet isolation and islet allograft survival. We tested our hypothesis by examining the effects of modified ET-Kyoto solution supplemented with sivelestat, a NE inhibitor (S-Kyoto solution), on islet yield and viability in islet isolation and the effect of intraperitoneally injected sivelestat on islet graft survival in a mouse allotransplant model. NE and proinflammatory cytokines such as tumor necrosis factor (TNF)-α and interleukin (IL)-6 increased markedly at the end of warm digestion during islet isolation and exhibited direct cytotoxic activity against the islets causing their apoptosis. The use of S-Kyoto solution significantly improved islet yield and viability. Furthermore, treatment with sivelestat resulted in significant prolongation of islet allograft survival in recipient mice. Furthermore, serum levels of IL-6 and TNF-α at 1 and 2 weeks posttransplantation were significantly higher in islet recipients than before transplantation. Our results indicated that NE released from activated neutrophils negatively affects islet survival and that its suppression both in vitro and in vivo improved islet yield and prolonged islet graft survival. The results suggest that inhibition of NE activity could be potentially useful in islet transplantation for patients with type 1 diabetes mellitus.

Reprogramming of mouse and human cells to pluripotency using mature microRNAs

Induced pluripotent stem cells (iPSCs) can be generated from differentiated human and mouse somatic cells using transcription factors such as Oct4, Sox2, Klf4, and c-Myc. It is possible to augment the reprogramming process with chemical compounds, but issues related to low reprogramming efficiencies and, with a number of protocols, residual vector sequences, remain to be resolved. We show here that it is possible to reprogram mouse and human cells to pluripotency by direct transfection of mature double-stranded microRNAs (miRNAs). Our approaches use a combination of mir-200c plus mir-302 s and mir-369 s family miRNAs. Because this reprogramming method does not require vector-based gene transfer, it holds significant potential for biomedical research and regenerative medicine.

Rapamycin causes upregulation of autophagy and impairs islets function both in vitro and in vivo

Autophagy is a lysosomal degradation process of redundant or faulty cell components in normal cells. However, certain diseases are associated with dysfunctional autophagy. Rapamycin, a major immunosuppressant used in islet transplantation, is an inhibitor of mammalian target of rapamycin and is known to cause induction of autophagy. The objective of this study was to evaluate the in vitro and in vivo effects of rapamycin on pancreatic β cells. Rapamycin induced upregulation of autophagy in both cultured isolated islets and pancreatic β cells of green fluorescent protein-microtubule-associated protein 1 light chain 3 transgenic mice. Rapamycin reduced the viability of isolated β cells and down-regulated their insulin function, both in vitro and in vivo. In addition, rapamycin increased the percentages of apoptotic β cells and dead cells in both isolated and in vivo intact islets. Treatment with 3-methyladenine, an inhibitor of autophagy, abrogated the effects of rapamycin and restored β-cell function in both in vitro experiments and animal experiments. We conclude that rapamycin-induced islet dysfunction is mediated through upregulation of autophagy, with associated downregulation of insulin production and apoptosis of β cells. The results also showed that the use of an autophagy inhibitor abrogated these effects and promoted islet function and survival. The study findings suggest that targeting the autophagy pathway could be beneficial in promoting islet graft survival after transplantation.

PLOD2 induced under hypoxia is a novel prognostic factor for hepatocellular carcinoma after curative resection

BACKGROUND

Under hypoxia, tumour cells undergo genetic and adaptive changes that allow their survival. Previously, we reported that high expression of hypoxia-inducible factor (HIF)-1 was a significant predictive factor for recurrence in hepatocellular carcinoma (HCC). Hypoxia also stimulates expression of procollagen-lysine, 2-oxoglutarate 5-dioxygenase (PLOD) genes via the HIF-1 pathway.

AIMS

The aim was to evaluate the relationship between hypoxia stress and expression of PLOD genes in HCC in vitro and to identify a new prognostic marker in HCC patients.

METHODS

The PLOD2 expression was assessed under hypoxia in hepatoma cell lines and characterized in 139 HCC samples following hepatic resection using microarray experiments, quantitative RT-PCR and immunohistochemistry. Prognostic factors in HCC patients were assessed using univariate and multivariate analyses.

RESULTS

The PLOD2 expression was induced under the hypoxia in vitro. Disease-free survival in the high PLOD2 expression group of HCC patients was significantly shorter when compared with the low-expression group (P = 0.002). In a subset of HCCs, we found that the PLOD2 expression of microarray was correlated with data of quantitative RT-PCR and immunohistochemistry. Of clinicopathological factors, PLOD2 expression was significantly correlated with tumour size (P = 0.022) and macroscopic intrahepatic metastasis (P = 0.049). In univariate analysis, six prognostic factors (tumour multiplicity, macroscopic intrahepatic metastasis, histological grade, microscopic portal invasion, microscopic intrahepatic metastasis and PLOD2 expression) were significant for disease-free survival. PLOD2 expression was identified as a significant, independent factor of poor prognosis (P = 0.013).

CONCLUSIONS

PLOD2 is a potential novel prognostic factor for HCC patients following surgery.

Direct growth of horizontally aligned carbon nanotubes between electrodes and its application to field-effect transistors

This paper presents direct growth of horizontally-aligned carbon nanotubes (CNTs) between two predefined various inter-spacing up to tens of microns of electrodes (pads) and its use as CNT field-effect transistors (CNT-FETs). Using the conventional photolithography technique followed by thin film evaporation and lift off, the catalytic electrodes (pads) were prepared, consisting of Pt, Al and Fe triple layers on SiO2/Si substrate. The grown CNTs were horizontally-aligned across the catalytic electrodes on the modified gold image furnace hot stage (thermal CVD) at 800 degrees C by using an alcohol vapor as the carbon source. Scanning and transmission electron microcopies (SEM/TEM) were used to observe the structure, growth direction and density of CNTs, while Raman spectrum analysis was used to indicate the degree of amorphous impurity and diameter of CNTs. Both single- and multi-wall CNTs with diameters of 1.1-2.2 nm were obtained and the CNT density was controlled by thickness of Fe catalytic layer. Following horizontally-aligned growth of CNTs, the electrical properties of back-gate CNT-FETs were measured and showd p-type conduction behaviors of FET.

[A case of successful surgical resection followed by S-1 administration for hepatocellular carcinoma with lung metastases and a tumor thrombus into right atrium]

A case of a 68-year-old man with hepatocellular carcinoma (HCC) is presented. He underwent partial liver resection for three times and transcatheter arterial chemoembolization (TACE) for three times. Follow-up CT revealed a recurrent hepatic surface mass with malignant extended into the inferior vena cava (IVC) and right atrium (RA). CT scan also revealed multiple metastatic nodules in bilateral lungs. The tumor thrombus into the RA and the hepatic surface mass were successfully treated with surgical resection. Pathological specimen allowed the diagnosis of poorly-differentiated HCC. Adjuvant chemotherapy with S-1 resulted in complete remission of lung metastases. Tumor markers showed a significant improvement after S-1 administration. This case report suggests that a surgical resection followed by S-1 administration would be effective for a patient with lung metastases and a tumor thrombus into IVC or RA.

[A case of intrahepatic cholangiocarcinoma with invasion to right adrenal gland]

A 64-year-old woman was admitted for epigastralgia. Abdominal computed tomography demonstrated a large tumor in the right lobe of the liver to adrenal grand. An aspiration tumor biopsy was performed because of difficulty in diagnosing the tumor, and the pathological findings suggested intrahepatic cholangiocarcinoma. At surgery right hepatic lobectomy with caudate lobe combined with right adrenal glandectomy and diaphragmectomy was performed. Pathological findings showed moderately differentiated tubular adenocarcinoma with invasion to right adrenal gland, but no lymph node metastasis was involved nor invasion of lymph vessel and vein. The postoperative course was uneventful and the woman remains recurrence-free for 12 months after the surgery.

[A case of successful second look operation for hepatocellular carcinoma with right atrial tumor thrombus]

We report a case of advanced hepatocellular carcinoma (HCC) with right atrial tumor thrombus treated by interferon (IFN)-combinated chemotherapies and second look operation. A case was a 56-year-old man who had right upper abdominal and back pain. The abdominal CT revealed an early enhanced lesion in the posterior segment of the liver with right atrial tumor thrombus. The patient underwent 2 courses of IFN-β/adriamycin combination therapy and followed by surgical resection. Due to severe congestive live, we only surgically resected tumor thrombi at right atrium, inferior vena cava, and right hepatic vein. Additionally, we closed posterior branch and right hepatic vein to prevent from a tumor progression. Following 16 months of IFN/5-FU and IFN/S-1 therapy, we performed a right posterior sectionectomy of the liver. Twelve months after the second operation, liver tumor relapsed and we performed transcatheter arterial chemoembolizatin, followed by IFN-combinateted chemotherapies. Thereafter, we continued chemotherapy for 14 months. The tumor progressed into the bile duct, and he died after 3 years and 8 months from the initial treatment. The case suggests that some patients with HCC with major vascular invasion and tumor thrombus can gain a long-term survival by multifocal treatment including surgery and chemotherapy.

[A case of successful surgical resection after repeated transcatheter arterial chemoembolization for far advanced multiple hepatocellular carcinomas in both lobes associated with Vp₂ portal vein tumor thrombus]

Treatments for hepatocellular carcinoma (HCC) include surgical resection, transcatheter arteral chemoembolization (TACE), percutaneous local therapy and systemic chemotherapy. However, it is difficult to perform a curative treatment for patients with far advanced multiple hepatocellular carcinomas. Here we report a case of successful surgical resection after repeated TACE for far advanced multiple hepatocellular carcinomas in both lobes associated with Vp₂ portal vein tumor thrombus. A 54-year-old male who had multiple HCC lesions in lateral, median and right lobes with portal vein tumor thrombus was admitted to our hospital. Three attempts of TACE resulted in a successful control of the tumors in the right lobe. Left hepatic lobectomy was therefore performed, and a relapse-free survival was obtained for over 5 years after surgery.