Safety and Efficacy of Upadacitinib for Atopic Dermatitis in Japan: Analysis of the 3-Year Phase 3 Rising Up Study

INTRODUCTION

Upadacitinib is an oral Janus kinase inhibitor approved in multiple countries for moderate-to-severe atopic dermatitis (AD). Here we present long-term data for up to 3 years of continuous upadacitinib treatment in Japanese patients with AD.

METHODS

Rising Up was a phase 3, randomized, multicenter study in Japan investigating the safety and efficacy of upadacitinib in patients with moderate-to-severe AD. Patients aged 12-75 years (weight ≥ 40 kg if < 18 years) were randomized 1:1:1 to receive upadacitinib 15 mg, upadacitinib 30 mg, or placebo through week 16 (all in combination with topical corticosteroids). At week 16, patients who received placebo were rerandomized 1:1 to upadacitinib 15 mg or 30 mg; topical corticosteroids were optional per investigator discretion from weeks 16-160. Safety was assessed by monitoring adverse events (AEs). Efficacy assessments included patients who achieved ≥ 75%/≥ 90% improvement from baseline in Eczema Area and Severity Index (EASI 75/90), clear/almost clear on the validated Investigator Global Assessment for Atopic Dermatitis (vIGA-AD 0/1), or a ≥ 4-point improvement from baseline in Worst Pruritus Numerical Rating Scale (WP-NRS).

RESULTS

Of 272 patients enrolled, 230 completed the study. Through week 160, the long-term incidence rate of overall AEs was numerically higher with upadacitinib 30 mg than 15 mg; rates of serious AEs, AEs considered possibly related to study drug, AEs leading to discontinuation, and AEs of special interest were generally low and similar between dose groups. EASI 75, EASI 90, vIGA-AD 0/1, and WP-NRS response rates were generally greater with upadacitinib 30 mg than 15 mg and maintained through week 160 with either dose.

CONCLUSION

For up to 3 years of continuous treatment, upadacitinib was well tolerated in Japanese patients, with a similar safety profile to that of short-term studies and durable long-term response rates for skin clearance and itch improvement.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, NCT03661138.

Effectiveness of Cardiac Rehabilitation for Prevention and Treatment of Sarcopenia in Patients with Cardiovascular Disease - A Retrospective Cross-Sectional Analysis

OBJECTIVE

Sarcopenia is a syndrome characterized by progressive and generalized loss of skeletal muscle mass and strength, with the risk of frailty and poor quality of life. This study aimed to clarify the clinical characteristics of sarcopenia and to investigate the effects of comprehensive cardiac rehabilitation (CCR), including nutrition, physical exercise and medication, in patients with cardiovascular disease (CVD).

METHODS

We retrospectively studied 322 inpatients with CVD (age 72±12 years). Muscle mass, muscle strength and physical performance were assessed before and after exercise training in patients with and without sarcopenia, which was defined as either a gait speed of <0.8 m/s or reduced handgrip strength (<26 kg in males and <18 kg in females), together with lower skeletal muscle index (SMI) (<7.0 kg/m2 in males and <5.7 kg/m2 in females). The actual daily total calorie and nutrient intake was also calculated.

RESULTS

Sarcopenia was identified in 28% of patients with CVD, these patients having a higher prevalence of symptomatic chronic heart failure and chronic kidney disease. SMI was significantly associated with protein intake and statin treatment. The ratio of peak VO2 and SMI was significantly higher in the statin treatment group. Handgrip strength, gait speed, leg weight bearing index, and nutritional intake improved after exercise training in patients both with and without sarcopenia.

CONCLUSIONS

The present findings suggest that CCR is a promising strategy for prevention and treatment of sarcopenia in patients with CVD.

Oddi's sphincter dysfunction

In the last decade, the controversy of sphincter of Oddi dysfunction (SOD) as a clinical entity has abated. The challenges facing clinicians caring for patients with suspected SOD are to effectively and safely diagnose and treat these patients. Sphincter of Oddi (SO) manometry (SOM) remains the gold standard for the diagnosis of SO dysfunction SOD. Several non-invasive screening tests for patients with pancreaticobiliary pain have been developed because SOM is associated with significant complications. Ultrasonography is useful for screening of organic pancreaticobiliary diseases but not for functional ones. Although magnetic resonance cholangiopancreatography (MRCP) is a safe, noninvasive method of examining the pancreaticobiliary tree abnormalities, it may currently have limited use in patients with suspected SOD. Quantitative hepatobiliary scintigraphy (QHBS) appears to become a promising method for identification of patients with biliary type SOD, and it should be employed prior to invasive diagnostic tests. ERCP for patients with type III SOD must be coupled with diagnostic SOM of both biliary and pancreatic sphincters since there are a high concordance of dual sphincter dysfunction. SOM is currently the gold standard of choice for evaluating SOD is the best predictor of outcome from sphincter ablation in type II and type III patients regardless of whether there is pancreatic or biliary SOD. In pancreatic SOD patients, biliary sphincterotomy alone may be inadequate for a treatment for some pancreatic type II patients. Medical therapy for SOD using smooth muscle relaxants has been disappointing and surgical therapy may play a role in limited number of cases that failed endoscopic therapy. Endoscopic intrasphincteric injection of Botulinum toxin is effective in patients with SOD and has minimal risks but it provides short-term efficacy. It may play a role as a first line diagnostic challenge, predicting which patient may ultimately respond to endoscopic sphincterotomy.

Cloning of cDNA for UDP-glucose pyrophosphorylase and the expression of mRNA in rice endosperm

Rice endosperm UDP-glucose pyrophosphorylase (UGPase) cDNA clones were isolated by screening a lambda ZAP II library prepared from poly (A(+)) RNA of japonica rice (cv Sasanishiki) endosperm with a probe of potato UGPase cDNA. One cDNA clone, possessing about 1,700 nucleotides, contained the complete open reading frame of rice UGPase. At the nucleotide-sequence level, the UGPase cDNA of rice endosperm had high homology with the UGPase cDNA of barley endosperm (84%) and potato tuber (71%). The calculated molecular weight (50 kDa) agrees with the value determined by SDS-PAGE (51 kDa). At the amino-acid sequence level, rice UGPase has high homology with the UGPase of barley (92%) and potato (85%). The enzyme contained conserved sequence elements which are thought to be involved in substrate binding and catalytic activity. A Southern-blot analysis indicated that the gene existed as a single copy. Expression of the enzyme in rice endosperm examined by Northern-blot analysis was high at 10-15 days after heading.

Carcinoma arising in choledochocele

BACKGROUND AND STUDY AIMS

Choledochocele has a potential for carcinogenesis, but no report has described malignant changes of the choledochocele in relation to pancreaticobiliary reflux because its anatomic form does not fit the criteria of pancreaticobiliary malunion (PBM). The aims of this study were to analyze the amylase level in bile in patients with choledochocele and to clarify whether the presence of a choledochocele predisposed to carcinoma.

PATIENTS AND METHODS

Records of 2826 patients who had undergone endoscopic retrograde cholangiopancreatography between 1995 and 1999 were reviewed for the presence of choledochocele and/or periampullary carcinoma. As an evidence of pancreaticobiliary reflux, amylase activity was examined in common duct bile obtained at surgery or by endoscopy. The prevalence of periampullary carcinoma was compared between patients with and without choledochocele.

RESULTS

A total of 11 patients were diagnosed as having a choledochocele. The amylase level in bile was higher in patients with choledochocele (120,922 +/- 62,269 IU/l; n = 4) than in previously examined patients with functioning gallbladders (15 +/- 24 IU/l; n = 10, P = 0.005). The prevalence of periampullary carcinoma in patients with choledochocele (27%, 3/11) was significantly higher than that in those without choledochocele (0.9%, 26/2815; P<0.0002).

CONCLUSION

The bile analysis of the present study presents one possible explanation for the predisposition to carcinoma in choledochocele as bile containing amylase may stagnate in the choledochocele and then carcinoma may develop in the inner epithelium of the choledochocele by the same mechanism as that leading to carcinogenesis in patients with PBM.

Quantitative analysis of hTERT mRNA expression in colorectal cancer

OBJECTIVES

Telomerase is highly activated in a variety of malignant neoplasms including colon cancer. Among the major components of telomerase, human telomerase reverse transcriptase (hTERT) is thought to regulate telomerase activity. To assess the importance of telomerase for the diagnosis of colorectal cancer, we measured the expression of hTERT mRNA and telomerase activity in a large series of 140 colorectal cancers, 140 adjacent normal tissues, and 20 adenomas.

METHODS

The expression level of hTERT was measured quantitatively by competitive reverse transcriptase-polymerase chain reaction (RT-PCR), and telomerase activity was examined by telomeric repeat amplification protocol (TRAP) assay in the same samples.

RESULTS

The median expression level of hTERT mRNA in carcinomas was significantly higher than that in either adenomas or normal tissues. The median level of hTERT in adenomas was significantly higher than that in normal tissues. Telomerase activities in carcinomas were significantly higher than those in either adenomas or normal tissues. Telomerase activities in adenomas were also significantly higher than those in normal tissues. Furthermore, the relative expression levels of hTERT mRNA in adenomas and carcinomas were significantly correlated with the relative telomerase activities; the Spearman rank correlation was 0.53 (p = 0.021) and 0.18 (p = 0.031), respectively.

CONCLUSIONS

Our data suggest that determination of hTERT mRNA by competitive RT-PCR is superior in quantitative accuracy and sensitivity and would support the importance of telomerase activity for the diagnosis of colorectal cancer.

Possible role of telomerase activation in the multistep tumor progression of periampullary lesions in patients with familial adenomatous polyposis

OBJECTIVES

The role of telomerase in periampullary tumor progression in patients with familial adenomatous polyposis (FAP) was investigated.

METHODS

Relative telomerase activity was measured using a telomerease amplification protocol in periampullary biopsy specimens of normal mucosa and adenoma obtained from patients with FAP, and was compared with that of periampullary normal mucosa and cancer specimens from patients without FAP.

RESULTS

None of normal mucosa from the non-FAP patients showed a telomerase ladder. Telomerase was positively detected in three of seven normal mucosa (42.9%) and in five of seven adenoma from FAP patients (62.5%). In papillary cancer from the non-FAP patients, seven of nine tissue specimens (77.8%) showed positive activity. When semiquantitatively analyzed, the relative telomerase activity increased in accordance with the progression of the diseases.

CONCLUSIONS

Telomerase is activated even in normal mucosa of FAP patients, and the intensities of telomerase may reflect the malignant potential of periampullary neoplasms.

Diverse effects of 9-hydroxyellipticine on the chemosensitivity of human pancreatic cancer cells harboring p53 mutations

Recently, it has been shown that 9-hydroxyellipticine (9-HE), an antitumor alkaloid has a unique property of restoring functional wild-type (wt) p53 activity via inhibition of mutant (mt) p53 protein phosphorylation. In the present study, we investigated the effect of 9-HE on the drug sensitivity of human pancreatic cancer cells. Exposure of cells to 9-HE at a relatively low concentration of 1 microM induced almost no cell death but was sufficient to restore wt p53 activity, as evidenced by an induction of endogenous p21WAF1/CIP1 concomitant with G1 and G2/M arrests in cell-cycle progression. Pretreatment with 1 microM 9-HE markedly enhanced cell killing when combined with cisplatin or mitomycin C. In contrast, 9-HE pretreatment protected cells from killing by 5-fluorouracil, VP-16, or vincristine. These effects of 9-HE were specific for several cell lines containing mt p53 and were not observed in p53-negative or wt p53 expressing cells. Taken together, these findings suggest that 9-HE may exert different effects on the drug sensitivity of pancreatic cancer cells displaying p53 mutations possibly through restoration of wt p53.

Quantitative determination of apoptotic death in cultured human pancreatic cancer cells by propidium iodide and digitonin

We present here the efficacy of an in vitro cytotoxicity assay which can measure rapidly both apoptotic dead cells and cell growth rate, quantitatively. Using a multi-well plate reader, the fluorescence intensity of propidium iodide (PI) corresponding to dead cells and to total cells after digitonin treatment were measured in cultured human pancreatic cancer cells following exposure to etoposide. The percentage of dead cells measured by this assay was well correlated to that determined by Trypan blue staining. Furthermore, the cell growth rate determined simultaneously was also correlated to the cell number counted directly using a microscope. We demonstrate that this method, which was originally established for evaluating necrosis, could be applied to measure apoptotic cell death. Taken together, this simple assay is useful for testing the efficacy of anti-cancer agents and for investigating the molecular mechanisms of apoptosis in the cultured cells.

Adenovirus-mediated p53 gene transduction inhibits telomerase activity independent of its effects on cell cycle arrest and apoptosis in human pancreatic cancer cells

Evidence for a relationship between overexpression of wild-type p53 and telomerase activity remains controversial. We investigated whether p53 gene transduction could cause telomerase inhibition in pancreatic cancer cell lines, focusing on the relation of transduction to growth arrest, cell cycle arrest, and apoptotic cell death. The cells were infected with recombinant adenovirus expressing wild-type p53 or p21WAF1 at a multiplicity of infection of 100 or were continuously exposed to 10 microM VP-16, which is well known to induce apoptosis. Adenovirus-mediated p53 gene transduction caused G1 cell cycle arrest, apoptosis, and resultant growth inhibition in MIA PaCa-2 cells; the cell number 2 days after infection was 50% of preinfection value, and 13% of the cells were dead. Moreover, the transduction resulted in complete depression of telomerase activity through down-regulation of hTERT mRNA expression. In contrast, p21WAF1 gene transduction only arrested cell growth and cell cycle at G1 phase, and VP-16 treatment inhibited cell growth with G2-M arrest and apoptosis; after treatment, the cell number was 73% of pretreatment, and 12% of the cells were dead. Neither p21WAF1 gene transduction nor VP-16 treatment caused telomerase inhibition. Similar results were obtained in two other pancreatic cancer cell lines, SUIT-2 and AsPC-1. Thus, our results demonstrate that the p53 gene transduction directly inhibits telomerase activity, independent of its effects on cell growth arrest, cell cycle arrest, and apoptosis.

Activation of telomerase and its diagnostic application in biopsy specimens from biliary tract neoplasms

BACKGROUND

Telomerase activity has been reported to have potential as a useful diagnostic marker for cancer in various organs. The authors previously reported that telomerase activity in pancreatic juice differentiates pancreatic ductal carcinoma from adenoma and pancreatitis. In the current study, the usefulness of semiquantitatively determined telomerase activity in the diagnosis of malignant biliary tract neoplasms was investigated.

METHODS

The samples examined included 61 surgically resected biliary tract tissues (11 gallbladder carcinomas, 5 bile duct carcinomas, 1 gallbladder adenoma, 30 cholecytitis cases, 7 cholesterol polyps, 1 normal gallbladder, and 6 normal common bile duct tissues), 42 bile samples from patients with biliary tract or pancreatic disease (19 cases of malignant biliary tract disease, 11 cases of benign biliary tract disease, 10 cases of malignant pancreatic disease, and 2 cases of benign pancreatic disease), and 14 bile duct biopsy specimens collected by percutaneous transhepatic choledochoscopy or endoscopic retrograde cholangiopancreatography (8 bile duct carcinoma specimens, 1 bile duct adenoma specimen, and 5 hepatolithiasis specimens).

RESULTS

In biliary tract tissues, a telomerase ladder was detected in 73% of gallbladder carcinomas, 40% of bile duct carcinomas, and none of the other biliary tract tissues. One gallbladder adenoma showed a weak telomerase ladder. The telomerase ladder was detected in the bile sample from 1 patient (5.3%) with malignant biliary tract disease, none of the patients with benign biliary tract disease, 5 patients (50%) with malignant pancreatic disease, and none of the patients with benign pancreatic disease. In biopsy specimens, the telomerase ladder was detected in 75% of patients with bile duct carcinoma but not in any of the patients with hepatolithiasis. The median value of relative telomerase activity in the patients with bile duct carcinoma was significantly higher than that in the patients with hepatolithiasis. The diagnosis of bile duct carcinoma was confirmed preoperatively by histopathologic examination in only 25% of the biopsy specimens.

CONCLUSIONS

The results of the current study indicate that telomerase is highly activated in biliary tract carcinomas and that the detection of a telomerase ladder in biopsy samples is an excellent tool for the diagnosis of bile duct carcinomas.

Activation of telomerase and its diagnostic application in biopsy specimens from biliary tract neoplasms

BACKGROUND

Telomerase activity has been reported to have potential as a useful diagnostic marker for cancer in various organs. The authors previously reported that telomerase activity in pancreatic juice differentiates pancreatic ductal carcinoma from adenoma and pancreatitis. In the current study, the usefulness of semiquantitatively determined telomerase activity in the diagnosis of malignant biliary tract neoplasms was investigated.

METHODS

The samples examined included 61 surgically resected biliary tract tissues (11 gallbladder carcinomas, 5 bile duct carcinomas, 1 gallbladder adenoma, 30 cholecytitis cases, 7 cholesterol polyps, 1 normal gallbladder, and 6 normal common bile duct tissues), 42 bile samples from patients with biliary tract or pancreatic disease (19 cases of malignant biliary tract disease, 11 cases of benign biliary tract disease, 10 cases of malignant pancreatic disease, and 2 cases of benign pancreatic disease), and 14 bile duct biopsy specimens collected by percutaneous transhepatic choledochoscopy or endoscopic retrograde cholangiopancreatography (8 bile duct carcinoma specimens, 1 bile duct adenoma specimen, and 5 hepatolithiasis specimens).

RESULTS

In biliary tract tissues, a telomerase ladder was detected in 73% of gallbladder carcinomas, 40% of bile duct carcinomas, and none of the other biliary tract tissues. One gallbladder adenoma showed a weak telomerase ladder. The telomerase ladder was detected in the bile sample from 1 patient (5.3%) with malignant biliary tract disease, none of the patients with benign biliary tract disease, 5 patients (50%) with malignant pancreatic disease, and none of the patients with benign pancreatic disease. In biopsy specimens, the telomerase ladder was detected in 75% of patients with bile duct carcinoma but not in any of the patients with hepatolithiasis. The median value of relative telomerase activity in the patients with bile duct carcinoma was significantly higher than that in the patients with hepatolithiasis. The diagnosis of bile duct carcinoma was confirmed preoperatively by histopathologic examination in only 25% of the biopsy specimens.

CONCLUSIONS

The results of the current study indicate that telomerase is highly activated in biliary tract carcinomas and that the detection of a telomerase ladder in biopsy samples is an excellent tool for the diagnosis of bile duct carcinomas.

Centrosome abnormalities in pancreatic ductal carcinoma

The centrosome plays an important role in microtubule nucleation and organization, ensuring the establishment of cell polarity and balanced chromosome segregation. Recent studies have suggested that the loss of cell polarity and/or chromosome missegregation (aneuploidy) in human malignant tumors could result from defects in centrosome function. Using immunofluorescence analysis with an antibody to gamma-tubulin (a well-characterized centrosomal component), we examined surgically resected human pancreatic tissues for centrosome abnormalities. The tissues included ductal carcinomas (n = 13), adenomas (n = 3), endocrine tumors (n = 3), chronic pancreatitis (n = 5), and normal pancreatic tissues (n = 12). We found that most (85%) carcinomas and some adenomas displayed abnormal centrosome profiles, characterized by an increase in size and number of centrosomes, and by their irregular distribution. In contrast, none of normal ductal and stromal tissues showed these abnormalities. These findings suggest that centrosome abnormalities may develop at a relatively early stage of pancreatic ductal carcinogenesis.

9-Hydroxyellipticine inhibits telomerase activity in human pancreatic cancer cells

There is increasing interest in identifying potent inhibitors of telomerase because the enzyme plays a crucial role in the development of cellular immortality and carcinogenesis. We hypothesized that 9-hydroxyellipticine (9-HE), an antitumor alkaloid, would inhibit telomerase activity because the drug has a unique mechanism of inhibiting phosphorylation of mutant p53 protein via inhibition of protein kinases, thereby restoring wild-type p53 function. This study was conducted to examine the effect of 9-HE on telomerase activity in human pancreatic cancer cells with differing p53 gene status. 9-HE treatment at relatively high concentrations resulted in rapid, complete inhibition of telomerase activity, irrespective of the p53 status. We conclude that 9-HE may exert a strong inhibitory effect on telomerase activity possibly through inhibition of protein kinases rather than through restoration of functional wild-type p53.

Telomerase activity detected in pancreatic juice 19 months before a tumor is detected in a patient with pancreatic cancer

We report a patient with pancreatic cancer in whom telomerase activity had been detected in the pancreatic juice 19 months before he was diagnosed as having pancreatic cancer. A 61-yr-old alcoholic man complaining of epigastric and back pain was diagnosed as having groove pancreatitis based on the presence of inflammation in the pancreatic head and its extension to the duodenal mucosa with an associated elevated serum amylase level. All imaging modalities showed no sign of a tumor. However, high telomerase activity was detected in the pancreatic juice collected during endoscopic retrograde pancreatography. His symptoms subsided due to abstinence from alcohol. A tumor, however, was recognized on computed tomography 19 months later, at which time the patient immediately underwent a pylorus-preserving pancreaticoduodenectomy. The carcinoma was located mainly in the Santorini duct region. High telomerase activity in the pancreatic juice may precede clinical detection of pancreatic cancer and thus could be a useful early diagnostic marker for pancreatic cancer.

Pancreatic carcinoma in remnant pancreas after pancreatectomy for mucinous cystadenoma

There are very few benign or malignant diseases which arise in the remnant pancreas after pancreatectomy. Pancreatic carcinoma in the remnant pancreas after pylorus preserving pancreatoduodenectomy (PpPD) for mucinous cystadenoma in a 66-year-old Japanese man is reported in this paper. The patient underwent PpPD for a mucinous cystadenoma in the pancreatic head 39 months prior to the present operation. The surgical margins of the PpPD specimen were free from atypical cells. Follow-up ultrasonography revealed a hypoechoic lesion in the body of the remnant pancreas. Magnetic resonance cholangiopancreatography (MRCP) revealed a stenosis of the main pancreatic duct, with upstream dilatation in the remnant pancreas. Segmental resection of the remnant pancreas, splenectomy, pancreaticojejunostomy and intraoperative radiotherapy were performed under the diagnosis of pancreatic carcinoma of the remnant pancreas. Final histopathological diagnosis was adenocarcinoma of the pancreas. There were no malignant cystic components. The present pancreatic carcinoma was regarded as independent of the previous mucinous cystadenoma. Postoperative radiation therapy and chemotherapy were added. He is doing well 20 months after the second operation although diabetes mellitus has slightly deteriorated. In this communication, we would like to recommend that clinicians should constantly be on guard against the development of pancreatic carcinoma even in the remnant pancreas after pancreatectomy for mucinous cystadenoma.

[Specific activation of telomerase in pancreatic cancer tissue and preoperative diagnosis of pancreatic cancer by telomerase in pancreatic juice]

Telomerase activity was measured in surgically resected tissues in various pancreatic diseases. Relative telomerase activity was expressed as the number of MIA PaCa-2 cells containing an equivalent activity in 1 microgram protein from samples. Telomerase activity in carcinomas was significantly higher than in the other nonmalignant pathologic states. Subsequently, telomerase activity was measured in pancreatic juice from patients with carcinoma, adenoma, and pancreatitis. Telomerase activity in carcinoma samples was significantly higher than that in either pancreatitis or adenoma samples as in tissue samples. High activity of telomerase in pancreatic juice indicates the existence of pancreatic cancer and may serve as a diagnostic tool.

Telomerase activity in pancreatic juice differentiates ductal carcinoma from adenoma and pancreatitis

Telomerase activity was measured in pancreatic juice obtained by endoscopic retrograde pancreatography from 34 patients (12 with ductal carcinoma, 12 with pancreatic adenoma, and 10 with pancreatitis). The activity in pancreatic juice was expressed as the number of cells of a human pancreatic cancer cell line, MIA PaCa-2, that exhibit an activity equal to that expressed in 1 microg of protein from pancreatic juice. A telomerase ladder was detected in the pancreatic juice obtained from a majority of the patients with ductal adenocarcinoma. The median value of relative telomerase activity in the carcinoma samples was 9.38 (25th percentile, 3.14; 75th percentile, 95.8), a value significantly higher than that derived from patients with either pancreatitis or pancreatic adenoma (P < 0.0001). When a threshold value of relative telomerase activity of 3.00 was used, 75% (9 of 12) of the samples obtained from patients with ductal carcinoma were positive. We conclude that telomerase activity in pancreatic juice differentiates adenocarcinoma from adenoma and pancreatitis and may serve as a useful diagnostic tool.

[A case of advanced gastric cancer with liver metastasis disappeared by oral administration of 5'-deoxy-5-fluorouridine after absolute non-curative operation]

A 64-year-old male was found to have a gastric cancer (Borrmann type 3) on the posterior wall of the stomach. Histological diagnosis was poorly differentiated adenocarcinoma. Ultrasonography revealed a hypoechoic lesion (18 x 14 mm) in the anteroinferior segment (S5) of the liver. The biopsy specimens from those lesions proved to be poorly differentiated adenocarcinoma. Total gastrectomy and distal pancreatosplenectomy were performed. During the operation, other liver metastases were found in the anterosuperior segment (S8) and inferolateral segment (S3). 5'-deoxy-5-fluorouridine (800 mg/day) was administered per os from the 33 rd postoperative day. The hypoechoic lesion of S5 in liver disappeared in the 17th postoperative month. The man is healthy with no evidence of recurrence 47 months after the operation. This case is very important because of the long-term CR.

Intersegmental connection with aberrant hepatic duct

A 66-year-old Japanese woman whose cystic duct drained into an aberrant bile duct was found to have an intersegmental connection bridging the right anterior and posterior ducts. The patient had cholelithiasis but no history of hepatic trauma, lending support to congenital etiology for the intersegmental duct. In the presence of aberrant bile ducts, a meticulous search may reveal such biliary communications.

[Peritoneal dissemination of cecal cancer disappearing in a patient taking 5'-DFUR for 3 years]

A 51-year-old woman presenting with a left ovarian tumor underwent left oophorectomy and hysterectomy with intraperitoneal administration of cisplatin, cyclophosphamide, and 5-fluorouracil on December 13, 1989. Microscopically the tumor was well-differentiated adenocarcinoma. Postoperatively cecal cancer was detected. Laparotomy revealed multiple peritoneal dissemination on March 23, 1990, when palliative ileocecal resection was performed. Microscopy revealed several of the nodules to be adenocarcinoma and the cecal lesion well differentiated adenocarcinoma. The patient was then placed on 5'-deoxy-5-fluorouridine (800 subsequently 600 mg/day). In November, 1991, bright red blood per rectum led to the discovery of rectal cancer. On January 26, 1993, laparotomy revealed rectal tumor invading the bladder but the metastatic nodules on the peritoneum had disappeared. Thus pelvic exenteration was performed. The tumor was well-differentiated adenocarcinoma. The ovarian lesion may have been a metastasis from the cecal cancer, a so-called Krukenberg tumor. The rectal cancer was most likely to be asynchronous cancer. 5'-DFUR seemed effective in remitting the peritoneal dissemination.

Thyroid gland metastasis from renal cell carcinoma masquerading as nodular goitre

Renal cell carcinoma metastasizing to the thyroid gland, in a 72 year old Japanese woman, is reported. The patient had undergone a left radical nephrectomy for renal cell carcinoma 3 months prior to the present operation. The patient noticed a nodular goitre but there was no evidence of any systemic spread of renal cell carcinoma. The histopathologic diagnosis, from a left lobectomy of the thyroid gland, was thyroid gland metastasis from renal cell carcinoma in adenomatous goitre. Clinical manifestation of thyroid gland metastasis from renal cell carcinoma, with no evidence of systemic involvement, is seen rarely. A case is reported and the condition discussed briefly.

Composite glandular-endocrine cell carcinoma of the extrahepatic bile duct: immunohistochemical study

A composite glandular-endocrine cell carcinoma of the extrahepatic bile duct in a 64 yr old Japanese man is reported. A nodular polyp measuring 1.9 x 1.1 cm was located in the confluence of the extrahepatic bile duct. Histologically, the tumor was composed of well differentiated tubular adenocarcinoma and small cell neuroendocrine carcinoma with a transition between the 2 components. The 2 areas of the tumor immunohistochemically revealed a clear-cut difference in functional differentiation. Tumor cells in the glandular component were immunoreactive to both carcinoembryonic antigen (CEA) and CAM 5.2, while those in the small cell area were immunoreactive to neuroendocrine markers such as neuron specific enolase (NSE), chromogranin A and serotonin. These results suggest that the tumor arose from a multipotential stem cell capable of differentiation in 2 directions.